Setting up a successful nurse-led intravitreal injections service: pearls from Swindon

Abstract

The demand for performing intravitreal injections has increased in recent years, prompting the need for more nurse training in their administration. The Great Western Hospitals NHS Trust in Swindon has developed a structured nurse training programme and now has 8 independent nurse injectors trained to undertake injections independently; nurse practitioners now contribute upwards of 85% of the total number of injections. The authors have also demonstrated the financial benefits of using injection assistant devices and shown the positive impact such devices have on training. In September 2019, the authors organised the first course to offer nurses and doctors hands-on experience in administering injections, using the Swindon training model to provide participants with a structured approach to learn how to perform intravitreal injections safely. Nurses made up 96% of participants; the remainder were doctors and managers; 6% had never performed an intravitreal injection; of units where they had, disposable drapes and a speculum were used in 71% of these. The number of injections performed per session at participants' units at the time they attended the course was: 17 or more injections=46%, 13–14=39%, and 11–12=15%. The course was rated 8.9/10 overall for content, with 85% very likely to recommend it to colleagues. All participants indicated that using the Swindon model made them feel confident to deliver injections safely. The authors demonstrated that using a structured training protocol and intravitreal assistant device improves the quality of nurse training and increases confidence in administering intravitreal injections.

Current methods of nurse-surgeon training and education: Systematic review

“…Another study ( Duncan et al., 2017 ) that was conducted in Australia found that through the government initiative to train nurses to perform endoscopic procedures, a successful expansion of their surgical capacity ensued. Furthermore, the results of the 12 studies that initiated a local nurse-surgeon training and education programme within their hospitals were consistent in reporting the positive impact of nurse-led surgery models of care in terms of the improvement in the surgical waitlist and the timely provision of essential surgical services ( Hasan et al., 2020 ; Gallagher, 2017 ; Shum et al., 2010 ; Hickey et al., 2009 ; Goodfellow et al., 2003 ; Duthie et al., 1998 ; Moshakis et al., 1996 ; Spiegel, 1995 ; Maule, 1994 ; DiSario and Sanowski, 1993 ; White et al., 1987 ; Rosevelt et al., 1984 ). Although the aim of our review was to identify and describe the current methods of nurse-surgeon training and education, the discussion of our findings regarding its implementation history is also vital particularly in leveraging the potential of nurse-surgeons to the international and national key stakeholders.…”

“…(1998) United Kingdom Quantitative descriptive To design and evaluate a training programme for nurse endoscopists 215 colorectal patients examined by trained nurse practitioner 215 Hospital Endoscopy Unit Training hospital Gastroenterology (flexible sigmoidoscopy) Not stated Gallagher (2017) United Kingdom Quantitative descriptive To determine the patient satisfaction of patients having nurse led intravitreal therapy 100 patients undergoing nurse led intravitreal therapy 100 Hospital Day Surgery Training hospital Ophthalmology (intravitreal therapy) Not stated Goodfellow et al. (2003) United Kingdom Quantitative descriptive To describe the first full year of independent practice by a newly appointed nurse endoscopist in a district general hospital in the United Kingdom 282 patients who underwent nurse-led flexible sigmoidoscopy 282 Hospital Endoscopy Unit Training hospital Gastroenterology (flexible sigmoidoscopy) Not stated Hasan et al. (2020) United Kingdom Quantitative descriptive To describe the Swindon model of training nurses to be independent intravitreal therapy injectors 22 ophthalmic nurses Not stated Hospital Day Surgery Training hospital Ophthalmology (intravitreal therapy) Not stated Hickey et al.…”

“… Clinical supervisor (consultant ophthalmologists) assessed the competency using protocols and criteria approved by the local quality improvement team. Goodfellow et al., 2003 (United Kingdom) Flexible sigmoidoscopy Colorectal Nurse Practitioner in first year of independent practice 1 year Delivered by the University of Hull in the United Kingdom Surgeon supervised involving 35 observations, 35 withdrawals, and 35 full procedures Surgical competency was achieved on completion of the training Hasan et al., 2020 (United Kingdom) Intravitreal therapy Ophthalmic Nurse Practitioner 12 weeks There is a theoretical component, but details were not provided Surgeon supervised involving 50 observations and 50 procedures 50 single best-answer questions (pass mark 100%), all competencies must be signed off prior to independent practice Hickey et al., 2009 (United Kingdom) Sapheno-femoral disconnection, long saphenous vein stripping, avulsions, and wound closure Qualified Surgical Care Practitioner with a Master of Science qualification in Advanced Nursing Practice and completed Royal College of Surgeons of Edinburgh Basic Surgical Skills and Anatomy courses Not stated Skills in varicose vein surgeries were taught by a consultant surgeon in six training modulesduring surgical lists Practicum based on the same standard set for surgical trainees. A surgeon supervised all aspects of the training.…”

Safety and efficacy of nurse led intravitreal injection service with Precivia® injection assist device

“…The department also developed a 12-week training pathway for nurses from induction session to delivering independent intravitreal injection session 13 . Between 2015 and 2020, the number of nurse injectors in the department increased from three to seven while maintaining the standard of injections and keeping patients’ satisfaction at a high level 14 .…”

Safety and efficacy of an artificial intelligence-enabled decision tool for treatment decisions in neovascular age-related macular degeneration and an exploration of clinical pathway integration and implementation: protocol for a multi-methods validation study

“…Treatment takes the form of intravitreal injections (IVIs) of anti-vascular endothelial growth factor (anti-VEGF) agents which are recommended for variable periods of time and at varying intervals depending on changes in the retina observed through OCT 15 16. While the decisions about treatments often involve ophthalmologists, the injections themselves are increasingly performed independently by specialised nurse practitioners and allied health professionals 17 18. Given the highly protocolised, OCT-dependent, nAMD treatment pathway and pre-existent clinical AI capable of independently quantifying the OCT features which inform that treatment, there is a clear opportunity for AI-enabled nAMD services to expand capacity and reduce avoidable real-world sight loss 12 16…”