Transformational change: nurses substituting for ophthalmologists for intravitreal injections - a quality-improvement report.
BACKGROUND
The dramatic increase in need for anti-vascular endothelial growth factor (anti-VEGF) intravitreal therapy in the treatment of retinal disease and the absence of an equivalent increase in ophthalmologists to undertake such intravitreal injections created a patient-safety risk. Timing of intravitreal therapy (IVT) is critical to prevent vision loss and local clinics lacked capacity to treat patients appropriately. We aimed to improve capacity for IVT by nurse injections.


METHODS
A multidisciplinary prospective service-improvement process was undertaken at two adjacent general hospitals in the northwest of England. IVT injections by nurses were a principal component of solution development. After we had obtained appropriate institutional approval, experienced ophthalmic nurses were trained, supervised, and assessed to undertake IVT. Ophthalmologists directly supervised the first 200 injections, and a retina specialist was always on site.


RESULTS
Nurses undertook 3,355 intravitreal injections between June 2012 and November 2013, with minor adverse events (0.3% subconjunctival hemorrhage and corneal abrasion). There were no patient complaints at either hospital.


CONCLUSIONS
Experienced ophthalmic nurses quickly learned how to perform such injections safely. IVT by nurses was well accepted by patients and staff. Hospital A trained three nurses sequentially for improved flexibility in scheduling. Novel use of appropriately trained non-medical staff can improve efficiency and access in an overburdened service with time-sensitive disease. Retinal assessment was undertaken by ophthalmologists only. Improved access to IVT is important, as treatment with anti-VEGF therapy reduces blindness at population levels.
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Monica M
MM
Michelotti
Ophthalmology Department, East Lancashire NHS Trust, Blackburn, UK.
Salwa
S
Abugreen
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Simon P
SP
Kelly
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Jiten
J
Morarji
Ophthalmology Department, East Lancashire NHS Trust, Blackburn, UK.
Debra
D
Myerscough
Ophthalmology Department, East Lancashire NHS Trust, Blackburn, UK.
Tina
T
Boddie
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Ann
A
Haughton
Ophthalmology Department, East Lancashire NHS Trust, Blackburn, UK.
Natalie
N
Nixon
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Brenda
B
Mason
Ophthalmology Department, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK.
Evangelos
E
Sioras
age-related macular degeneration; extended roles; nurse; ophthalmology; retina; transformation