Post date: 
Tuesday, 9 June 2015

Setting up a service to deliver ocular drug injections involves much more than just the practical training, as specialists at Moorfields tell Radhika Holmstrom.

“At Moorfields, we now have a six-day service and 60 to 70 per cent of injections are delivered by nurses,” says Adam Mapani, Moorfields’ hospital’s first nurse consultant who works with a cohort of 45 trained nurse practitioners.
“We’re rarely refused – it’s not an innovation anymore.” He and his colleagues are now offering training to the increasing number of other hospitals which are also going down the route of using nurses to deliver intravitreal drug injections. However, they are also very clear that setting up a service involves more than simply training nurses in a technique.
The need for intravitreal injections has increased dramatically with the use of anti-VEGFs for macular degeneration – and it is now expanding further, as the treatment being used for patients with diabetic retinopathy and retinal vein occlusions. Originally the official position, including the Royal College of Ophthalmologists (RCOPth)  guidelines, was that these injections should be delivered only by doctors but even the college  has changed its position, while a study presented to the most recent Association for Vision and Ophthalmology supports the evidence that the procedure is equally safe whether carried out by nurses or doctors
“Nursing staff should be involved in dealing with injections; and expanding that into injecting into the eye is a logical step,” says Robin Hamilton, Moorfields’ lead age-related macular degeneration (AMD) consultant.  

Training enquiries

 “A lot of departments in the UK – probably about 60 per cent – are running non-medical delivered services,” says Mapani. Yet it is still a relatively new procedure and many of those departments have asked for assistance from Moorfields in getting it underway.
Moorfields has now run two courses on ‘Implementing a Non-Medical delivered Intravitreal injection service’. These are mainly attended by senior nurses, but there are also orthoptists, optometrists, managers and consultant ophthalmologists.
“There has been a massive increase in phone contact and consultation; the courses save us time,” explains Mapani. “I’ve had people contact me from Australia, New Zealand, Europe – including Scandinavia – and Singapore. They all want to know about licensing, training, how to identify people who are capable of doing this – and the general feeling among doctors.” The two courses have been designed specifically to address those concerns: the training considerations and also the issues relating to planning, implementation, funding and supervision.  

Not just the practicalities

Part of the training does focus on the practical specifics – notably a ‘wet lab’ session where participants learn how to inject artificial eyes under the supervision of three senior consultant ophthalmologists. “The majority of the nurses taking part would have seen this before,” says Mapani. “We show them all the techniques and safety elements, and also how to prepare their hands.” However, although the more experienced people do gain the practical skills to start delivering injections, this is not the only outcome: in fact the wet lab session is scheduled at the very end of the day. The training is in setting up a whole service. 
That involves learning about the medical and legal issues, as well as the safest way to deliver the injections – after all, it is still quite recently that the UK brought in the practice of delivering the injections in theatre rather than in an office (which has cut the risk of infection to one in 4,000 to 5,000 from one in 300).  “A unit may be under pressure to deliver 10,000 injections a year, and we need to make sure it is safe and effective. We have gone through a full process and drawn up a protocol, which was originally with lawyers for over a year and which we’re now proactively sharing with everyone. We also have an ongoing safety and infection audit, which is very valuable because in order to deliver a good service you need to make sure that what you are doing is safe,” says Hamilton. Accordingly, the ‘medico-legal and governance issues’ section of the day course involves four separate speakers with their own specialities, along with a question and answer session.
Obviously safeguards and a process like this take up more time and money than just training up nurses in the technique and expecting them to start delivering, but they are essential. Hamilton adds: “The label on the drug says it should be injected by a trained ophthalmologist. In reality nurses can deliver the service but they shouldn’t be expected to run the whole thing; the accountability has to rest with us. In the same way, nurses should not inject without a consultant present – not necessarily in the same room, but overseeing the process. 
“Our biggest concern is that a nurse is doing something unsupported. I don’t think that is appropriate, and I would never expect a nurse to do something I can’t do or would not be willing to be around. The very rare situations where you get an increase in pressure in the eye do require medical staff there and then.”  

Sharing and reflecting

The other aspect of the training course relates more directly to nursing. “Nursing is very qualitatively driven,” Mapani points out. “We are happy to share experiences: how people felt when they did their injections, how it feels to have like Robin Hamilton looking over your shoulder, how it feels when the patient asks if you have done this before, and so on. 
“Later in the programme I have invited practitioners with varying levels of experience to come in and talk about their work in depth. It’s also good to share those areas that can be done differently, as part of ‘reflective practice’.”
Again, this goes beyond the clinical procedure. “Giving an injection is an art,” says Mapani. “Are you going to do it mechanically, without talking to the patient, or talk it through giving them that level of reassurance they need? We encourage the person assisting to ask if the patient needs their hand held to reassure them. You’re not just delivering the injections but delivering the psychological support.” For hospitals which give patients fixed slots, he and his colleagues encourage nurse practitioners to deal with the same patients each time, to help them build up their confidence. “You get to know each other.”

Keeping the interest up

A non-medical intravitreal injection service is an effective – and cost-effective – way of using the existing expertise – but it’s not a quick fix.  Hamilton’s view is that practitioners should be limited to a maximum of sessions a week maximum, so that they remain interested and do the job to the best of their ability. That means that quite a few people need to be trained in the techniques, quite apart from the protocols and safeguards that also need to be in place. 
That said, it is well worth doing – from a professional as well as a patient point of view. “I think it’s great, what we’re doing here,” Hamilton concludes. “Nurses enjoy doing this and they enjoy the extra responsibility. If you are sitting in a canteen and you are one of the nurses doing intravitreal injections you’ll feel head and shoulders above the others.”

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