Abstract
Background
To describe the design, implementation, and evaluation of a nurse-led intravitreal injection (NL-IVT) programme in a Singapore tertiary eye hospital.
Methods
Patients requiring anti-vascular endothelial growth factor (VEGF) IVT were recruited. Implementation and evaluation were done in the Singapore National Eye Centre, a tertiary centre. To assess safety, nurse injectors recorded details of procedures performed and complications for an 8-month period from February 2019. To evaluate patient experience, we used a modified patient questionnaire and recorded both patients’ waiting time and IVT procedure duration. A retrospective audit of IVTs before and after the introduction of NL-IVT was performed from January 2017 to September 2019. Cost difference between NL-IVT and standard doctor-led (DL) IVT was evaluated.
Results
A total of 8599 NL-IVTs were performed. No cases of severe complication were detected in the follow-up. A total of 135 patients who received NL-IVT and DL-IVT were surveyed. General satisfaction, interpersonal manner, financial aspect, time spent with injector, and staff competence were higher in NL-IVTs than in DL-IVTs (p < 0.05). There were no differences in terms of technical quality and communication. For 934 patients, waiting time was significantly shorter in NL-IVT (3.6 ± 10.3 min) compared with DL-IVTs (35.3 ± 32.3 min); on average, 19.7 min were saved through NL-IVT (p < 0.01). The cost difference per IVT between NL-IVT and DL-IVT is estimated at 286 SGD (163 GBP).
Conclusion
With a well-designed training programme, NL-IVT is a safe, acceptable, and cost savings procedure. With increasing demand for IVT, NL-IVT provides an alternative model of care for healthcare systems globally.
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Change history
11 February 2021
A Correction to this paper has been published: https://doi.org/10.1038/s41433-020-1077-8
References
Lim LS, Mitchell P, Seddon JM, Holz FG, Wong TY. Age-related macular degeneration. Lancet. 2012;379:1728–38.
Yau JW, Rogers SL, Kawasaki R, et al. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35:556–64.
Wong WL, Su X, Li X, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. Lancet Glob Health. 2014;2:e106–116.
Spooner KL, Mhlanga CT, Hong TH, Broadhead GK, Chang AA. The burden of neovascular age-related macular degeneration: a patient’s perspective. Clin Ophthalmol. 2018;12:2483–91.
Kataja M, Hujanen P, Huhtala H, Kaarniranta K, Tuulonen A, Uusitalo-Jarvinen H. Outcome of anti-vascular endothelial growth factor therapy for neovascular age-related macular degeneration in real-life setting. Br J Ophthalmol. 2018;102:959–65.
Martin DF, Maguire MG, Fine SL, et al. Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results. Ophthalmology. 2012;119:1388–98.
Cohen SY, Mimoun G, Oubraham H, et al. Changes in visual acuity in patients with wet age-related macular degeneration treated with intravitreal ranibizumab in daily clinical practice: the LUMIERE study. Retina. 2013;33:474–81.
Holz FG, Tadayoni R, Beatty S, et al. Multi-country real-life experience of anti-vascular endothelial growth factor therapy for wet age-related macular degeneration. Br J Ophthalmol. 2015;99:220–6.
Leasher JL, Bourne RR, Flaxman SR, et al. Global estimates on the number of people blind or visually impaired by diabetic retinopathy: a meta-analysis from 1990 to 2010. Diabetes Care. 2016;39:1643–9.
Rogers S, McIntosh RL, Cheung N, et al. The prevalence of retinal vein occlusion: pooled data from population studies from the United States, Europe, Asia, and Australia. Ophthalmology. 2010;117:313–319.e311.
McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004;329:258.
DaCosta J, Hamilton R, Nago J, et al. Implementation of a nurse-delivered intravitreal injection service. Eye. 2014;28:734–40.
Simcock P, Kingett B, Mann N, Reddy V, Park J. A safety audit of the first 10 000 intravitreal ranibizumab injections performed by nurse practitioners. Eye. 2014;28:1161–4.
Michelotti MM, Abugreen S, Kelly SP, et al. Transformational change: nurses substituting for ophthalmologists for intravitreal injections—a quality-improvement report. Clin Ophthalmol. 2014;8:755–61.
Rasul A, Subhi Y, Sorensen TL, Munch IC. Non-physician delivered intravitreal injection service is feasible and safe—a systematic review. Dan Med J. 2016;63. pii: A5229.
Austeng D, Morken TS, Bolme S, Follestad T, Halsteinli V. Nurse-administered intravitreal injections of anti-VEGF: study protocol for noninferiority randomized controlled trial of safety, cost and patient satisfaction. BMC Ophthalmol. 2016;16:169.
Gregg E. Nurse-led ranibizumab intravitreal injections in wet age-related macular degeneration: a literature review. Nurs Stand. 2017;31:44–52.
Samalia P, Garland D, Squirrell D. Nurse specialists for the administration of anti-vascular endothelial growth factor intravitreal injections. N Z Med J. 2016;129:32–38.
Li E, Greenberg PB, Krzystolik MG. Nurse-administered intravitreal injections: a systematic review. Graefes Arch Clin Exp Ophthalmol. 2015;253:1619–21.
Mohamed R, Ramcharan D, Srikaran S, Mensch E. A model of clinical practice: a randomised clinical study evaluating patient satisfaction of nurse-led vs consultant-led intravitreal injection. Eye. 2018;32:1148–9.
Gallagher MJ. Introduction of a nurse-led intravitreal injection service in ophthalmology. Br J Nurs. 2017;26:800–3.
Hasler PW, Bloch SB, Villumsen J, Fuchs J, Lund-Andersen H, Larsen M. Safety study of 38,503 intravitreal ranibizumab injections performed mainly by physicians in training and nurses in a hospital setting. Acta Ophthalmol. 2015;93:122–5.
Bolme S, Morken TS, Follestad T, Sorensen TL, Austeng D. Task shifting of intraocular injections from physicians to nurses: a randomized single-masked noninferiority study. Acta Ophthalmol. 2019;98:139–44.
Ng WY, Cheung CM, Mathur R, et al. Trends in age-related macular degeneration management in Singapore. Optom Vis Sci. 2014;91:872–7.
Ng WY, Tan GS, Ong PG, et al. Incidence of myocardial infarction, stroke, and death in patients with age-related macular degeneration treated with intravitreal anti-vascular endothelial growth factor therapy. Am J Ophthalmol. 2015;159:557–564.e551.
Marshall GN, Hays RD. The patient satisfaction questionnaire short-form (PSQ-18). Santa Monica, CA: Rand; 1994.
Mason JO 3rd, White MF, Feist RM, et al. Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection. Retina. 2008;28:564–7.
Fintak DR, Shah GK, Blinder KJ, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina. 2008;28:1395–9.
Fileta JB, Scott IU, Flynn HW Jr. Meta-analysis of infectious endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic Surg Lasers Imaging Retin. 2014;45:143–9.
Mohsin M, Forero R, Ieraci S, Bauman AE, Young L, Santiano N. A population follow-up study of patients who left an emergency department without being seen by a medical officer. Emerg Med J. 2007;24:175–9.
Boudreaux ED, O’Hea EL. Patient satisfaction in the emergency department: a review of the literature and implications for practice. J Emerg Med. 2004;26:13–26.
McMullen M, Netland PA. Wait time as a driver of overall patient satisfaction in an ophthalmology clinic. Clinical ophthalmology. 2013;7:1655.
Ansah JP, Koh V, de Korne DF, et al. Projection of eye disease burden in Singapore. Ann Acad Med Singap. 2018;47:13–28.
Michelotti MM, Abugreen S, Kelly SP, et al. Transformational change: nurses substituting for ophthalmologists for intravitreal injections–a quality-improvement report. Clin Ophthalmol. 2014;8:755.
More P, Almuhtaseb H, Smith D, Fraser S, Lotery AJ. Socio-economic status and outcomes for patients with age-related macular degeneration. Eye. 2019;33:1224–31.
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THR was a scientific advisor to Medi-Whale Inc. THR received stocks as a part of the standard compensation package; potential conflicts of interests are managed according to the institutional policies of the Singapore Health System (SingHealth). TYW is an inventor of a patent on the various deep learning system in ophthalmology; potential conflicts of interests are managed according to the institutional policies of the Singapore Health System (SingHealth) and the National University of Singapore. The remaining authors declare no competing interests.
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This retrospective cross-sectional study was conducted in accordance with the declaration of Helsinki and approved by the Singhealth Centralised Institutional Review Board.
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Teo, A.W.J., Rim, T.H., Wong, C.W. et al. Design, implementation, and evaluation of a nurse-led intravitreal injection programme for retinal diseases in Singapore. Eye 34, 2123–2130 (2020). https://doi.org/10.1038/s41433-020-0920-2
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DOI: https://doi.org/10.1038/s41433-020-0920-2
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