# A Closed-Loop Audit: The Assessment of Red Flags and Management of Acute Conjunctivitis in Primary Care

## TL;DR

This audit evaluated how primary care doctors assess and manage red eye, finding that interventions improved red flag checks but antibiotic use remained high.

## Contribution

A practical closed-loop audit with interventions to improve red flag assessment and management of acute conjunctivitis in primary care.

## Key findings

- Before interventions, 97.6% of patients had laterality documented and 1.8 red flags assessed on average.
- After interventions, 3.8 red flags were assessed per patient on average, showing significant improvement.
- Despite improvements, 73.8% of patients were still prescribed antibiotics, even with few bacterial cases identified.

## Abstract

Background

Acute red eye is a common presenting complaint to primary care. Although conjunctivitis is the most common cause, some conditions can be sight-threatening. Diagnosing such conditions can be difficult given the broad differential diagnoses and limited specialist equipment. The National Institute for Health and Care Excellence (NICE) has published five "red flags," which may indicate the need for urgent ophthalmological assessment: reduced visual acuity (VA), copious discharge, marked eye pain/photophobia, contact lens use and recent trauma. For patients not requiring specialist referral, NICE recommends conservative management and reserving antibiotics for non-resolving/severe cases.

Aims

The primary objective of this audit was to improve the assessment and documentation of acute red eye in primary care. The secondary outcome was to evaluate management appropriateness.

Methodology

We conducted a closed-loop audit to evaluate the clinical assessment and management of acute red eye within a single primary care practice. All cases coded as "conjunctivitis" or "acute red eye" over a one-year period were included. The following aspects of the clinical assessment were explored: symptom duration, laterality and red flag assessment. The conjunctivitis type diagnosed (bacterial, viral, allergic or unspecified) and management strategies were recorded.

The audit introduced a multi-faceted intervention to improve the assessment and management of red flag symptoms in patients presenting with acute red eye. A practice meeting was conducted to raise awareness about the importance of assessing for red flag symptoms and adhering to guidelines. Additionally, a standardised template for GPs to use during consultations and a text message patient questionnaire for telephone consultations were implemented. The impact of these implementations was reassessed after one year.

Results

Over a one-year period, 42 cases were identified. On average, patients presented after 2.4 days of symptoms. Overall, 97.6% (41/42) documented symptom laterality. On average, each patient had 1.8 red flags assessed. One patient had red flag symptoms and was correctly referred to same-day ophthalmology services. Out of 42 patients, 41 were diagnosed with unspecified conjunctivitis, while one was diagnosed with viral conjunctivitis. Although there were zero recorded cases of bacterial aetiology, 73.8% (31/42) were prescribed antibiotics and 16.7% (7/42) were given hygiene advice and a deferred antibiotic drops script, while only 7.1% (3/42) were managed conservatively.

Post-interventions, 13 cases were identified. On average, each patient had 3.8 red flags assessed (p<0.001). Only one patient was identified as having red flag symptoms and reduced VA and was referred to ophthalmology services. Out of the 13 patients, 12 were diagnosed with unspecified conjunctivitis, while one was diagnosed with bacterial aetiology; 15.3% (2/13) were managed conservatively, while the remaining 84.6% (11/13) were prescribed antibiotics. Two out of the 11 patients given antibiotics were prescribed fusidic acid, having been refractory to chloramphenicol.

Conclusion

This audit demonstrated that significant improvements in clinical assessment of conjunctivitis can be achieved through practical and inexpensive interventions. However, antibiotic prescribing remained high despite limited bacterial diagnoses. Further efforts are needed to sustain improvements and reduce unnecessary antibiotic use.