Cataract Clinical Care Standard

A patient with visual problems due to suspected cataract requires an ocular examination, preferably performed using a slit lamp biomicroscope or direct ophthalmoscope, and an assessment of how their visual problems are affecting their life. Optometry referral may be a suitable initial option for assessment of cataract.

Discuss the possible options to manage the patient’s symptoms and advise them that the presence of cataract alone is not an indication for surgery. Patients with lens opacities that do not cause visual symptoms or limit daily activities can continue to be managed and monitored in the primary care setting.

Consider referral for possible cataract surgery when patients have visual impairment that interferes with their ability to carry out their usual daily tasks, considering the possible impact on their ability to live independently. Ocular or medical comorbidities may affect the urgency of referral. Visual impairment can include reduced visual acuity, or disabling glare or contrast sensitivity. Vision-related activity limitations may include a loss of ability to work, drive, carry out daily tasks, or care for themselves or others – for example, an increased risk of falls in older people with risk factors. Box 1 provides information about assessment of vision-related activity limitation and some examples of assessment tools, see Cataract Clinical Care Standard full document.

Discuss the potential benefits and harms of cataract surgery, including the disadvantages of poor vision and the risks of complications. Assess the patient’s willingness to proceed with surgery if it is offered. Ophthalmology assessment can confirm whether patients with ocular comorbidity are more likely to benefit from surgery, or have an increased risk of complications.

If referral is appropriate, check the referral criteria for the receiving service you are referring to, because requirements may differ between services. Ensure that all required information is provided; use a standardised cataract referral template if one is available. Both general practice and optometry assessment may be needed to provide the information required. Improving the quality of the referral can reduce delays for patients by helping ophthalmology services triage access to ophthalmology services and assess medical suitability for surgery. Elements of a comprehensive referral that may be required by local referral guidelines are listed in Box 2, see Cataract Clinical Care Standard full document.

If the patient does not to want to consider cataract surgery and there are no other indications for ophthalmology assessment, referral to an ophthalmology service may not be appropriate. Provide support for patients to reduce the impact of their visual problems, including refractive correction, tinted lenses to reduce glare, or use of suitable equipment to optimise vision and improve the patient’s capacity for activities of daily living.⁷ Refer to an optometrist, orthoptist, occupational therapist or vision clinic or other provider of low-vision services, if appropriate.

Primary care services making referrals should maintain awareness of any local referral guidelines or criteria for referral to ophthalmology or other eye services and have protocols to ensure that relevant information is included in the patient referral. Patient information about cataract and its management should be available for primary care clinicians to provide to patients. Information on any alternative community-based referral options should also be available.

Ophthalmology services receiving referrals should have guidelines that describe what information is required in referrals from primary care, and, where relevant, describe any criteria for accepting and prioritising referrals. This will usually be determined locally and take into account the availability of services, particularly in regional locations. Box 2 provides some of the components to consider in referral guidelines. Referral guidelines should be published online in an accessible, relevant location, and made readily available to referring clinicians and through Primary Health Networks, see Cataract Clinical Care Standard full document.

A standardised referral template can be effective for improving the appropriateness of referral, as well as improving the quality of information needed to triage patients for ophthalmology appointments.

Cataract is a common eye problem as people get older. General practitioners (GPs), Aboriginal health practitioners, optometrists and orthoptists are all primary care clinicians who may be your first point of contact for eye problems.

Cataract may be found as part of a routine eye test or because you are having trouble with your vision. Vision tests and an eye examination can identify whether you have cataract. These tests can be carried out by an optometrist or orthoptist, or by a specialist eye doctor (ophthalmologist). If you do have cataract, it is important for your clinician to understand how your visual problems are affecting your life, including the sorts of things that you can no longer do.

If cataract is not affecting your ability to carry out your usual activities, you may not need to consider surgery yet. Prescription glasses, or other equipment or aids might be worth considering – your optometrist, GP or low-vision service provider can advise you about the services available.

If cataract surgery is a suitable option for you and you are willing to consider surgery, your clinician can refer you to a specialist eye doctor for further assessment and to discuss possible surgery. Some specialist eye clinics will ask for specific information in your referral before they offer you an appointment. This might include eye test results from an optometrist, and information about other medical conditions and treatments from your GP or another clinician.

Provide patients who have cataract with clinically accurate, evidence-based information about their options, both verbally and in a written format that is easy to use – for example, in large font or electronically. Suitable options may include surgical or non-surgical options, such as visual aids or watchful waiting. Ask the patient about their needs, preferences, quality-of-life concerns and any psychosocial issues, to help you to support them in shared decision making.

Provide care that is culturally safe and respectful for Aboriginal and Torres Strait Islander people.

Ensure that policies support shared decision making and the competence of clinicians, who should be appropriately trained in shared decision making and have access to suitable resources. Ensure that any patient information resources provided are clinically accurate, balanced and evidence-based, and suitable to your patient population. These resources should include information about surgical and non-surgical options, be easy to understand, and be presented in a format that is easy to use for patients with impaired vision.

Provide a culturally safe environment for your patient community. The level of comorbidities in Aboriginal and Torres Strait Islander people, their age at diagnosis and disparities in their health outcomes means that health care for this population needs to be refocused to meet the unique needs of each patient.

Your clinician will talk to you about cataract and its treatment in a way that you can understand, and is respectful of your cultural needs and individual situation. Written information will be presented in a format that is easy for you to use. You will be informed about the available options, including their expected benefits and possible adverse outcomes – these might include unsatisfactory changes in your vision and more serious complications. You will be asked about the effect that vision problems are having on your life, and have the opportunity to discuss the advantages and potential disadvantages of surgery for your individual circumstances. Other options, including visual aids and watchful waiting, should also be discussed.

Use an agreed local protocol to allocate appointments for referred patients, prioritising them according to clinical need, including social and cultural circumstances and barriers to accessing care. This is particularly important if there are waiting times for the first specialist assessment.

Assessment of clinical need includes both visual impairment and resulting limitations in vision-related activities. Social factors, including the impact of poor vision on the person’s ability to work and live independently, should also be considered.

If the referral is incomplete, the referring clinician should be prompted for further information. The assessment should be scheduled in a time frame that is consistent with agreed health service protocols to ensure that patients are assessed in a timely way.

Referrals should be reviewed by a credentialed ophthalmic clinician who can use the information in the referral to make an initial assessment about the appropriateness of referral, severity of symptoms and relative priority for ophthalmological assessment. Use of standardised criteria and tools allows consistency of assessment, and assists when prioritising patients within a health service or system.

When patients are referred for consideration for cataract surgery, appointments are allocated using protocols that prioritise patients based on clinical need, including social circumstances, based on adequate information about the referred patient. This is particularly important in health service organisations that have substantial waiting lists for the first specialist assessment.

These protocols should describe criteria for accepting referrals and prioritising patients for ophthalmology assessment. They should include any tools to be used for providing standardised information, and allow for a credentialed ophthalmic clinician to review referrals to determine the priority and timing of ophthalmology assessments. In some states and territories, these protocols may be determined at a health department level for public hospital clinics.

Where referral criteria apply, these should be readily available and communicated to referring clinicians and patients. Consider providing a standardised referral template for referrals from the community to help ensure that adequate information is provided.

Protocols should include pathways for patients who do not meet referral criteria, who choose non-surgical options, or for whom surgery is considered unsuitable or inappropriate at ophthalmologic assessment. These pathways may include reassessment or follow-up, or referral to other services such as optometry, orthoptist, occupational therapy or vision clinics. Provide information back to the referring clinician.

Processes should be in place to monitor patients waiting for first ophthalmology appointments in case their clinical needs and priority change.

Monitor and audit outcomes within a quality improvement framework to assess whether desired outcomes are being achieved, including the time frame from referral to assessment and surgery.

When you are referred to a specialist eye doctor, you will usually be given the next available appointment. However, some clinicians or health services may use the information in your referral to decide when you receive an appointment. This means that people with more urgent needs may be seen more quickly. If you are referred to a health service or specialist eye doctor using this type of system, they will check the information in your referral to decide when you will receive an appointment. If key information is missing from your referral, they will ask you or the referring clinician to provide the missing details. If you are not ready for surgery, an optometrist may be able to suggest ways for you to manage your eye problems.

If your eyesight worsens or other circumstances change while you are waiting for an appointment, get in contact with the clinician who referred you and let them know.

• Note: This statement applies to people having cataract surgery primarily to improve vision.
  It does not apply to other indications for cataract surgery including angle closure and phacolytic glaucoma, or to allow monitoring of retinal conditions.

The clinical decision about whether to offer cataract surgery takes into account the patient’s level of visual impairment, the impact of visual deficits on their daily life, and the potential benefits and harms associated with surgery.

Visual acuity of 6/12 or worse may provide a useful objective measure of visual impairment, but may significantly underestimate function – for example, in conditions of high or low light. Glare or contrast sensitivity may be disabling without an impact on visual acuity. Some patients will have higher visual acuity needs, such as for occupational activities. Vision-related activity limitations include activities of daily living, which are specific to the individual’s social circumstances and occupation. Validated tools for assessing vision related activity limitations, and the impact of visual problems on activities and social functioning are described in Box 2, see Cataract Clinical Care Standard full document. Some of these tools correlate well with positive patient reported outcomes after cataract surgery.

Use of standardised criteria and tools allows consistency of assessment, and assists when prioritising patients within a health service or system. These criteria do not replace the need for an individualised clinical assessment or clinical judgements about the severity of impairment and the appropriate treatment options.

Most patients have an improvement in visual function after surgery. Patients most likely to report a poor outcome after surgery include those with good self-assessed preoperative visual function. Consider conditions that increase the risk of complications or a poor outcome from cataract surgery (such as diabetes, diabetic retinopathy or uveitis) or limit the extent of visual gain (such as age-related macular degeneration).

If the patient chooses not to have surgery or is not considered suitable for surgery at this time, offer details of other healthcare providers who can help, such as an occupational therapist or optometrist.

Ensure that protocols support the use of suitability criteria for cataract surgery, and that cataract surgery is offered to patients who meet agreed criteria. Protocols should allow other compelling indications for surgery to be considered, based on clinical judgement, and should cater for patients who choose non-surgical options.

Consider implementing common clinical criteria or tools into protocols to enable standardised assessment, documentation and prioritisation. Box 2 provides examples of tools that could be considered, see Cataract Clinical Care Standard full document. Implement tools and protocols within a quality improvement framework, monitoring their use and impact to ensure that desired outcomes are being achieved. Such outcomes may include whether criteria are being consistently applied, equity of access, timeliness of access and patient-reported outcomes.

Cataract surgery is usually recommended when you have trouble seeing well enough to carry out your normal daily activities. As part of your assessment, your clinician may test how clearly you can read an eye chart (visual acuity). They will also take into account other visual problems, including any difficulty you have seeing in bright or dim light.

You will be asked about how your eye problems affect your daily activities. What this means may differ from person to person. Daily activities include working, driving and reading, as well as your ability to live independently and safely with your visual problems (for example, whether you are at risk of falls). The clinician may ask you to complete a questionnaire.

The likely benefits and possible harms of surgery might depend on whether you have any other health conditions, including other eye problems. Your clinician will consider these factors when discussing the possibility of cataract surgery with you, and will let you know if you have a condition that means that surgery is not recommended or there is a higher risk of complications.

Sometimes cataract surgery is recommended for medical reasons rather than for improving vision. This includes surgery for people who need regular check-ups of the retina (back of the eye) but the retina cannot be seen because of the cataract.

Take into account organisational protocols for prioritising patients in your local health service, and provide information to assist structured and consistent prioritisation. Assess and document visual impairment and vision-related activity limitations, using a standardised tool if required.

At an individual patient level, the benefit of, and relative priority for, surgery are usually based on expert clinical judgement, taking into account the degree of visual impairment, the impact of visual impairment on activities of daily living (vision-related activity limitations), the risks of delayed surgery, any relevant comorbidity and the expected benefit of surgery.

When patients are being prioritised for surgery across a health service organisation, standardised protocols may be used to assess these factors systematically. Prioritisation protocols should enable those patients at greatest risk of harm from delayed surgery and those who are most likely to benefit from surgery to be treated first. Potential harms associated with delayed surgery include risks of falls or traffic accidents, or increased complexity of later surgery – for example, in patients with densely brunescent or white cataract. Social factors that may affect the ability of patients to access care, should also be considered, including remoteness, language and culture.

Comorbid conditions that may increase the urgency of cataract surgery should be considered in the prioritisation process. These include acute angle glaucoma and posterior segment disease, where fundal access is required for monitoring or treatment.

Ensure that protocols are in place to support prioritisation of patients according to their clinical needs and other key factors, based on a full ophthalmology assessment. Prioritisation protocols should include consideration of the patient’s visual impairment and vision-related activity limitations, comorbidity, potential harms from delayed surgery and potential to benefit. Social factors that may affect the ability of patients to access care should also be considered in protocols where relevant locally, including remoteness, language and culture. Surgery is scheduled based on this protocol. Monitor and, if necessary, reassess patients while they are on the waiting list in case their circumstances change.

Consider using validated tools or agreed clinical criteria to enable standardised assessment and documentation. Implement prioritisation protocols as per the requirement of the health service, or the state or territory health department. Examples of tools that could be considered and adapted are listed in Box 3, see Cataract Clinical Care Standard full document. Implement tools and protocols within a quality improvement framework, monitoring their use to ensure that desired outcomes are being achieved. These include whether criteria are being consistently applied, timeliness of surgery, clinician perceptions and patient-reported outcomes. Where there is variation, assess the effectiveness of prioritisation protocols in the context of NSQHS Action 1.28.

If you and your eye surgeon agree that you are likely to benefit from cataract surgery, and you agree to have surgery, this will be arranged.

Where there is a high need for services, you will be put on a waiting list for surgery. Most hospitals use a system that makes sure that patients with the greatest need for surgery are scheduled for cataract surgery first. This means that the severity of your vision problems and their impact on your life should be taken into account. For example, poor eyesight can affect your ability to work, drive, cook, read and write, or your ability to care for yourself or others. Your clinicians will also consider any other health conditions you have and your risk of falls. Some health conditions may make it more urgent for you to have cataract surgery, while others could mean that surgery is less likely to help you.

Let your GP, optometrist or eye specialist know if your vision worsens or other circumstances change while you are on a waiting list for cataract surgery.

Discuss second-eye surgery and its timing when first-eye surgery is being planned. Similar criteria apply when assessing the need for second-eye surgery as for the first eye (clinically significant visual impairment, vision-related activity limitations and comorbidities – see quality statements 4 and 5). In addition, consider existing or anticipated anisemotropia (a significant difference in refractive error between the two eyes) after first-eye surgery, and its impact on vision and visual function, including stereopsis (depth perception), stereoacuity and falls risk.

Advise patients of the options available and appropriate in their clinical circumstances. This may include no surgery, surgery on two separate days some time apart or second-eye surgery on the same or next day. Explain to patients what they can expect from having, or not having, second-eye surgery, and discuss the benefits and potential harms with them to help decide between options.

Having second-eye surgery later allows complete postoperative recovery (and, if needed, treatment of postoperative complications) from first-eye surgery, and the opportunity to assess and plan surgery based on the results of first-eye surgery. Make arrangements for second-eye surgery as soon as it is appropriate for the patient’s preferences and circumstances.

There is limited evidence to support second-eye surgery on the same or next day. It may be considered for patients

• at low risk of complications during and after surgery, or at risk from delayed second eye surgery
• to avoid a second general anaesthetic, when general anaesthetic is required
• for whom distance and travel are considerable barriers, such as in remote and very remote areas.

Ensure that patients are informed of the consequences of complications, including the risk of potentially blinding complications in both eyes, such as endophthalmitis or toxic anterior segment syndrome. Second-eye surgery may not be appropriate for some patients. As well as individual preference, some patients may have another eye condition that makes it too risky for them, or makes an improvement in vision less likely.

Provide access to current evidence-based guideline recommendations for second-eye surgery and support use of these recommendations by clinicians. Ensure the availability of protocols relating to decisions about second-eye surgery and its timing. For patients having delayed second-eye surgery, prioritise surgery according to clinical need.

If second-eye surgery on the same or next day is carried out in the health service, ensure that facilities are appropriately equipped, and that local protocols are in place to minimise the risk of complications and manage them should they occur.

If you have cataract in both eyes, your eye surgeon will discuss whether you would benefit from having surgery in both eyes. For many people, having cataract surgery in one eye is enough to improve vision. If your eye surgeon thinks you may need operations on both eyes, the options include:

• having surgery on the second eye weeks or months after the first eye has recovered from surgery
• having surgery on the second eye on the same day as the first eye or the day afterwards.
• how your overall vision is expected to change after surgery in the first eye – if one eye is very different from the other (for example, much more short-sighted), it may be hard to see clearly
• the risks of an infection or another complication. Although the risk of complications is small, having complications in both eyes could be very serious. If you are at high risk of complications or have other eye problems, having operations on both eyes at the same time may not be recommended
• your general health, any other eye problems, and your personal circumstances and preferences.

The option most suitable for you will depend on a number of factors. Some of the factors you should take into account include:

Discussing these issues with your eye surgeon, and understanding the potential harms and benefits will help you decide if and when you want to arrange surgery for your second eye, and how to go about doing so.

Evidence-based guidelines recommend use of intracameral antibiotics for endophthalmitis prophylaxis in preference to topical pre- or postoperative antibiotic eye drops. Therapeutic Guidelines: Antibiotic recommend cefazolin intracamerally as a single dose at the end of surgery, and avoiding use of quinolones or vancomycin, which lack evidence; consider the risk of antibiotic resistance. Prophylactic use of topical antibiotic solutions or eye drops is not recommended, and there is little evidence to support their use. If no commercially prepared intracameral formulation is available, antibiotic eye drops may be considered to avoid the risk of dilution errors and contamination. Seek advice in the case of patients with hypersensitivity to penicillin or cephalosporins. If postoperative antibiotic eye drops are used, chloramphenicol 0.5% eye drops are recommended. Stipulate the duration (maximum seven days) to avoid overuse.

Consider postoperative anti-inflammatory eye drops (corticosteroid eye drops, with or without non-steroidal anti-inflammatory drugs) for patients at high risk of developing cystoid macular oedema after cataract surgery, such as patients with diabetic retinopathy or other high-risk ocular comorbidities. Discuss the possible benefits and harms of these eye medicines with the patient. If they are used, provide clear instructions for their use, including duration of use.

Potential adverse effects include allergic reactions to antibiotics, increased intraocular pressure with corticosteroids and, rarely, epithelial damage with non-steroidal anti‑inflammatories.

Ensure that clinicians have access to current evidence-based guideline recommendations for intracameral antibiotics and other postoperative eye drops, such as Therapeutic Guidelines: Antibiotic. Develop processes to measure compliance with guidelines. Intracameral use of cefazolin is off-label, and its addition to the formulary will need to be approved by the local Drugs and Therapeutics Committee under routine use of an off‑label medicine.

Antibiotics are used in cataract surgery to prevent eye infections (called endophthalmitis). Although these infections are very rare, they can be very serious. Injecting an antibiotic into the eye during surgery is one of several things your eye surgeon will do to prevent infection. This is called an intracameral antibiotic. Antibiotic eye drops after surgery are usually not necessary if you have an injection.

Another type of eye drop (anti-inflammatory eye drops) may be used to reduce the risk of serious inflammation or swelling in the eyes. If your eye surgeon wants you to use anti‑inflammatory eye drops, they will discuss this with you and explain how to use the eye drops. With any eye drops, follow the dosing instructions carefully and only use them as long as you need to, to avoid using more than necessary.

Ensure appropriate postoperative care by regularly reviewing the patient’s postoperative recovery. Determine the exact frequency of postoperative review, taking into account the surgical technique, any operative or postoperative complications, and the person’s ability to access care. Early review (within 24 hours) may be warranted for patients at high risk of complications, but may be deferred for up to two weeks in uncomplicated cataract surgery in patients not at risk of intra-ocular pressure increase. Inform patients about the need for follow-up appointments and how to recognise potentially important visual changes. Provide details of who to contact in case of concerns.

Postoperative care is the responsibility of the operating ophthalmologist. If this is not possible – for example, for some rural and remote patients – care should be delegated to an appropriately qualified clinician with adequate clinical handover, considering the patient’s ability to access services. Ensure that this team member has the patient’s preoperative assessment and details of the surgery performed, is able to recognise complications, and can access urgent referral and specialist support if needed.

Provide patients with information about what to expect during the postoperative period, how to care for their eye postoperatively, use of medications, second-eye surgery (where relevant) and when to get new glasses (if appropriate). Include this information in reports back to the referring clinician, including details of intracameral antibiotics administered during surgery.

Ensure that clinicians have access to local guidelines or protocols for appropriate postoperative care, and that processes are in place to promptly identify and manage complications.

When postoperative care will be provided by a clinician other than the operating ophthalmologist, ensure appropriate handover of clinical information required to provide postoperative care. Ensure that systems are in place to provide patients with access to emergency specialist ophthalmology services as needed.

Ensure that policies and procedures for information management and communication support the reporting of surgical outcomes to referring clinicians, other relevant clinicians and the patient, and that responsibilities are clearly delineated.

Your eye surgeon (and members of the eye team) will see you regularly while you recover from cataract surgery, until your eyes have fully recovered from the surgery. Usually, this will mean a check-up in the first 48 hours and again 2–4 weeks after surgery. They will look at your eye to check how well it is healing and how well you can see. They will provide information about:

• what you can expect while your eye is healing
• how to look after your eye while it is healing, including any eye drops needed
• when to have your eyes checked after the operation so that any problems can be treated early, even though the risk of complications after surgery is usually low
• when to get new glasses, if this applies to you.

It is important that you know who to contact if you have any concerns or questions, or if your vision changes unexpectedly. If you have cataract in your non-operated eye, your eye surgeon will talk to you about your options for future surgery, usually based on the recovery of your operated eye.

A number of questionnaires and measures have been developed to assess the impact of cataract on patients’ daily lives and the benefit of cataract surgery. Although some have serious limitations,others have been validated and evaluated in English-speaking cataract populations:

• Catquest-9SF is a nine-item questionnaire that is recommended for pre- and post-surgery measurement of patient-reported outcomes by the International Consortium of Healthcare Improvement; it has been validated in Australia
• Cat-PROM5 is a five-item questionnaire recently developed in the United Kingdom for use in the National Health Service that compares favourably with CatQuest-9SF, but has not been validated in Australia.

• Ensure systems and processes support people to self-report their Aboriginal and Torres Strait Islander status and to record self-identification.
• Ensure all staff engage regularly in cultural safety training.
• Implement the six actions for Aboriginal and Torres Strait Islander Health from the NSQHS Standards.

• Provide flexible service delivery to optimise attendance and help develop trust with individual Aboriginal and Torres Strait Islander people and communities.
• Establish robust communication channels and referral pathways with primary healthcare providers (including Aboriginal Community Controlled Health Organisations [ACCHOs]).
• Where possible, provide outreach services close to home, on Country or in collaboration with ACCHOs or other community healthcare providers.

• Take a collaborative approach to ensure that interventions are suitably tailored to the individual’s personal needs and preferences for care.
• Encourage the inclusion of support people, family and kin or the person’s trusted healthcare provider (such as their ACCHO) in all aspects of care, including decision making and planning treatment and management.
• Engage culturally appropriate interpreter services and cultural translators when this will assist the patient.
• Involve Aboriginal and Torres Strait Islander Health Workers or Aboriginal and Torres Strait Islander Health Practitioners as part of a patient’s multidisciplinary team and involve Aboriginal and Torres Strait Islander Liaison Officers in hospital settings.
• Use culturally and linguistically appropriate materials to aid in communication and discussion, accounting for varying levels of health literacy.

Surgical Ophthalmology Service (SOS) - Royal Victorian Eye and Ear Hospital

A lack of referral criteria and poor-quality referrals were undermining capacity to efficiently triage patients. Almost half of patients were returned to the waiting list instead of progressing to surgery.

The Eye and Ear team addressed the congestion using a more structured triaging process, supported by clear criteria and guidelines for referring clinicians.

Improving referral processes to improve triage pathways for cataract patients

One-Stop Cataract Assessment (OSCA) Eye Clinic, Westmead Hospital

Patients at the outpatient Eye Clinic at Westmead Hospital were waiting up to 18 months for specialist assessment. The Westmead team identified areas where the nursing team could make a contribution, streamlining processes and increasing the clinic’s overall capacity.

In the OSCA Clinic, non-complex patients referred for cataract surgery have their initial ophthalmic assessments conducted by credentialled nurses.

Diverting assessment of routine patients to an upskilled nursing workforce

Nurse-led Cataract Postoperative Examination Eye Clinic, Westmead Hospital

The outpatient Eye Clinic at Westmead Hospital was challenged by congested clinics at every point of the patient pathway. The team selected day-one postoperative care examination as the trial ground for their first nurse-led clinic, piloted in 2018.

In the Nurse-led Cataract Postoperative Examination (NICE) Clinic, specially trained nurses manage postoperative care for routine cataract surgery, reducing overall waiting times without affecting the quality of care.

Streamlining the patient journey with nurse-led postoperative care

University Hospital Geelong, Barwon Health Victoria

Prescribing of postoperative topical antibiotics following cataract surgery is not routinely recommended, yet the practice remains common. The Antimicrobial Stewardship team at University Hospital Geelong resolved to address the inappropriate use of postoperative topical antibiotics in their service.

The intervention and response was quick, simple and successful.

Changing practice around the inappropriate use of postoperative topical antibiotics

The development of the Cataract Clinical Care Standard follows a recommendation in the Second Australian Atlas of Healthcare Variation (2017) to develop a Clinical Care Standard on cataract surgery. The Atlas found that Australia has twice the rate of cataract surgery (8,000 per million) compared to New Zealand, but less than that of France, the Netherlands and the United States. It also reported 1.6 fold geographical variation across local areas, following the exclusion of the highest and lowest results (includes public and private data).

Read more about the scope and goal of this Standard or see further background in the Cataract Clinical Care Standard.

This Standard applies to all healthcare settings where care is provided to patients with cataract, including primary care, hospitals, Aboriginal health services and privately operated eye clinics. Not all quality statements in this Standard will be applicable to every healthcare service or clinical unit. Healthcare services should consider their individual circumstances in determining how to apply each statement. 

When implementing this Standard, healthcare services should consider:

• the context in which care is provided
• local variation
• quality improvement priorities of the individual healthcare service. 

In rural and remote settings, different strategies may be needed to implement the standard. For example, the use of:

• hub‑and‑spoke models integrating larger and smaller health services and ACCHOs
• telehealth consultations
• multidisciplinary teams including allied health involvement where clinically appropriate.

This Standard relates to the care of patients with cataract aged 18 years and over. It covers the assessment of patients, decisions about cataract surgery and postoperative care.

The Standard articulates some key elements for an improved pathway of care, including referral, assessment and surgery. These include:

• Using consistent, clinically sound criteria for determining when cataract surgery may be appropriate
• Ensuring that referral of patients from primary care is informed by these criteria
• Allocating ophthalmic assessments before surgery according to clinical need, using essential information provided in the referral
• Prioritising patients for surgery according to clinical need and based on transparent criteria.
   

National Safety and Quality Health Service Standards

Monitoring the implementation of Clinical Care Standards helps healthcare services to meet some of the requirements of the:

• National Safety and Quality Health Service Standards (NSQHS Standards) for acute services
• National Safety and Quality Primary and Community Healthcare Standards (Primary and Community Healthcare Standards) for services that deliver health care in a primary and/or community setting. 

Find out more about how healthcare services are expected to implement the national standards in How to use the Clinical Care Standards.

The Commission is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians. 

Person-centred care recognises and respects differences in individual needs, beliefs, and culture. The Commission: 

• is committed to supporting healthcare services to provide culturally safe and equitable healthcare to all Australians
• acknowledges that discrimination and inequity are significant barriers to achieving high‑quality health outcomes for some patients from culturally and linguistically diverse communities.

Culturally safe service provision and environments are those where the places, people, policies and practices foster mutual respect, shared decision making, and an understanding of cultural, linguistic and spiritual perspectives and differences. Cultural safety is supported by organisations and individuals that recognise cultural power imbalances and actively address them by: 

• ensuring access to and use of interpreter services or cultural translators when this will assist the patient and aligns with their wishes
• providing visual or written information in a language that the patient, their family and carers will understand
• providing cultural competency training for all staff
• encouraging clinicians to review their own beliefs and attitudes when treating and communicating with patients
• identifying variation in healthcare provision or outcomes for specific patient populations, including those based on ethnicity, and responding accordingly.

The Cataract Clinical Care Standard has been endorsed by six key organisations:

• Australian College of Rural & Remote Medicine
• National Rural Health Alliance
• Optometry Australia
• Orthoptics Australia
• Society of Hospital Pharmacists of Australia
• Vision Australia.

The Commission develops Clinical Care Standards taking into account:

• advice from multidisciplinary topic working groups which include clinicians, consumers, and researchers
• consultation with key stakeholders including consumer bodies, professional organisations, and state and territory health departments. 

The Cataract Clinical Care Standard Topic Working Group provided expert advice in the development of the Standard. In addition, a public consultation process was conducted with key stakeholders.

Cataract Clinical Care Standard Topic Working Group

The role of the Topic Working Group was to:

• advise on the scope and key components of care for the Standard
• advise on key sources of evidence including clinical practice guidelines, standards and empirical literature to build upon the body evidence supporting the existing model
• advise on the formulation of quality statements and supporting indicators
• recommend strategies to support the implementation of the Standard
• actively support raising awareness of the Standard.

All members are required to disclose financial, personal and professional interests that could, or could be perceived to, influence a decision made, or advice given to the Commission. Disclosures are updated prior to each meeting and managed in line with the Commission’s Policy on Disclosure of Interests.

The quality statements in the Standard are based on the best available evidence and guideline recommendations at the time of development. 

Further information is available on the evidence sources underpinning the Standard.

Evidence sources - Cataract Clinical Care Standard