For World Diabetes Day, we explore how nurse practitioners are leading intravitreal dexamethasone implant services in the fight against DME
Phoebe Harkin | | Interview
Nurse practitioners had been performing invasive procedures in other specialities for almost two decades before the first publication highlighting their role in the delivery of intravitreal anti-VEGF drugs (1). But with a shortage of doctors and an aging population, the need to find creative means of delivering intravitreal pharmacotherapy has become more pressing.
Plymouth Eye Hospital decided to tackle the problem after an audit of their own consultant-led services revealed a significant delay in the delivery of intravitreal dexamethasone implant injection for DME after the clinical decision was made. Why? An inadequate number of injectors and limited capacity. The constraint in capacity was addressed by moving the service from the theater into a cleanroom in the outpatient setting. And two senior nurse practitioners with experience in intravitreal anti-VEGF injection were trained to deliver the intravitreal dexamethasone implant service.
Between February 2017 and October 2019, the two nurse practitioners administered 1,006 injections. More importantly, they reported zero cases of endophthalmitis or other visually significant complications, including retinal detachment, vitreous haemorrhage, hypotony, or iatrogenic cataract. How did the patients feel? A satisfaction survey was overwhelmingly positive, with the majority advocating for the continuation of the nurse-led service. The paper showcasing the project (1) made the case for experienced nurses who already provide anti-VEGF injections to inject the intravitreal dexamethasone implant (Ozurdex), streamlining the service and reducing waiting time for patients.
Alison Triggol – one of those nurse practitioners – holds the position of macular lead nurse at the Royal Eye Hospital, Plymouth. In honor of World Diabetes Day 2020 “Diabetes: Nurses Make the Difference,” we spoke with Ali about her experience administering the implant – and asked for her opinions on the evolving role of nurses in ophthalmology and DME treatment.
Please tell us more about the nurse-led trial...
We had to apply to the governor’s board to make the case for doing the project at all. We told them it would free up theaters for more pressing cases and made the argument that it’s cheaper for a nurse practitioner to perform injections in the outpatient department than a consultant in theater. Even when consultants get the chance, they typically only do one or two cases per session, so patients sometimes end up waiting five hours for a single injection. We asked patients to fill out a satisfaction questionnaire at the end of the trial and the majority said they were amazed at how quickly they were seen; as nurses, we could just fit them between other injection appointments. The satisfaction rates went from 58 percent with a consultant to 96 percent with nurses.
The reduced waiting times are one major reason – but why else do you think satisfaction improved?
As nurse practitioners, we’re so proficient at giving injections, the patient often feels less pain than they would in theater – and that’s with us only using topical anaesthetic. It’s also incredibly quick, taking the same amount of time as we would for an anti-VEGF injection.
Some doctors have reservations about nurses taking on such work. Did you have any doubts beforehand?
Ozurdex requires a completely different technique to anti-VEGF, so it was important to get the right training. I was taught by one of the consultants – Konstantinos Papadedes – who took me through the ins and outs of what could go wrong; for example, deflating the eye, causing a slow leak. I was initially a bit scared but after a lot of practice, you get a feel for it. We’ve had no complications so far.
One of the key takeaways from the paper is the benefit of nurse-led services. Was your experience positive overall?
Definitely. We have gone from doing two or three sessions a week to 15 or 16 sessions – it’s constant. Our aim is to offer a one-stop clinic for injections but we have so many patients in our catchment area, we can’t possibly provide it for everybody. Nurse-led clinics like ours frees up doctors to do more theater sessions – undoubtedly a good thing.
How do you think the role of nurses in ophthalmology is going to change?
It is becoming obvious that we’re going to have to take on more responsibility – and not just because of COVID-19. There is a general increase in numbers of patients presenting to ophthalmology departments, in part because the equipment we use is so advanced we can now see things we couldn’t before (generating more work), and also because people are living longer (so we’re treating them for longer). Morbidity rates are also increasing. The only issue is hiring the nurses – something we’re struggling with at the moment. The majority of nurse practitioners are 45-plus and all on the verge of retiring. We need new blood coming in but there is a reluctance – a squeamishness – amongst nurses to do ophthalmology. But unless we can recruit more, we’re going to have a big problem in the years to come.
Do you have any advice for practices looking to adopt your model?
Get a consultant who believes and trusts in nurse practitioners. I’ve given talks to nurses throughout the country about implementing these practices and I tell them: be positive and don’t be frightened of taking on new roles. Training takes time – it took me two months, and that was before COVID-19 – but once you refine your injection skills, patients can be in and out in 15 minutes. Everybody benefits.
How does ophthalmology compare with other specialities you’ve worked in?
They say the eyes are the windows of the soul, and it is true. We find that we often diagnose other non-ophthalmic problems when we see our patients – whether they’re going to have a stroke; if they have problems with their cholesterol; if they are at risk of diabetes. It is very beneficial being able to prevent further diseases this way. In ophthalmology, you tend to get to know your patients, and they get to know you as well, because they come back month after month for treatment – and that’s something I love.
Macular clinics in lockdown
How has your practice been affected by the pandemic?
Myself and another colleague – another full-time injector – have been trying to keep the macular clinics going; it’s very important that our patients don’t deteriorate. We’ve been busy offering a one-stop clinic throughout lockdown but it is only in the last month or so that we’ve struggled to cope with the numbers as people start to come out of isolation.
Are you anticipating another delay after this lockdown?
We noticed a change as soon as the government made the announcement. We’re not reducing our clinic hours but we’re already seeing patients not turn up for their appointments out of worry, particularly in the south west of the city where infection rates are worse now than they were in the first lockdown. The average age of a patient here is about 70 or 80 years old (not to mention three or four over 100) – and that does make them much more vulnerable. We’re also seeing more COVID-19 patients admitted to hospital. Fortunately, we have our own entrance and we are, of course, taking all the necessary safety measures, including social distancing and adequate PPE.
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- V Raman et al., “Safety of nurse-led intravitreal injection of dexamethasone (Ozurdex) implant service. Audit of first 1000 cases”, Eye, [Online ahead of print] (2020). PMID: 32728227