Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2025
CEQ Showcase 2025 - Ophthalmology Advanced Practice Nurse Model of Care
Summary
Establishing a nurse led interventional service for treatment of macular disease in Gold Coast Health.
Key dates
1 October 2023 - 1 February 2025
Aim
To offer an intravitreal injection (IVI) service where advanced practice nurses (APNs) perform intravitreal injections to help meet the growing demand for this service and provide greater service efficiency.
Outcomes
- Deliver 75% of the IVI clinics within our Health Service
- A total of 3383 QNAP funded cases (from Apr 2024 - Mar 2025) = QNAP revenue of $2,820,950.00
- Reduction in Ultra Long Waits (ULW) by 1084, Long Waits (LW) by 1300, and despite the ever-increasing demand the total Wait List (WL) has decreased by 1182 since the implementation of Interventional Clinical Nurse Consultants (ICNCs) (October 2023)
- Enabled an average of an additional 133 NEW appointments, 284 REVIEW appointments, and an increase in procedural slots by 61, per month
- Enhanced patient education
- Network established across GCHHS / SCHHS
- Model expanded - grown from 1 to 3 credentialled APN (Oct 23 - Feb 25)
Background
The introduction of the intravitreal injections of anti-VEGF medications for patients with macular disease such as Age-Related Macular Degeneration (AMD), Diabetic Macular Oedema (DMO), Retinal Vein Occlusion (RVO) Cystoid Macular Oedema (CMO) and other has been a major development in the treatment for patients in the medical retinal service.
Despite the implementation of programs to streamline services such as treat and extend medication regimes; few patients will ever be discharged from regular monitoring to detect disease reactivation.
There is increasing pressure on ophthalmic services to deliver intravitreal therapy in a timely manner to reduce and prevent vision loss, to an increasing amount of new and existing patients.
To offer an intravitreal injection service is where advanced practice nurses perform intravitreal injections will help meet the growing demand for this service and provide greater service efficiency, with the following points being met:
- The patient always remains under the care of a named consultant ophthalmologist.
- The health professional is fully trained in the rationale for treatment, its effects, and possible complications, both intra and post-procedure.
- The health professional is fully trained in the technique of injection by an ophthalmic specialist doctor.
- The health professional always has immediate access to advice from an ophthalmic specialist doctor while giving the injections, and an ophthalmic specialist doctor must be available to manage any complications.
- There is a continuous audit of the injection service provided by health professionals. There should also be regular patient feedback. Further training must be available to the health professional if required.
- The Hospital and Health Service management is fully aware of and supports the initiative, and all personnel are covered by appropriate indemnity.
- Regular Hospital and Health Service guidelines on delegation of consent must be followed.
- The training of Ophthalmic doctors in the technique of intra-ocular injections is essential. Additional parallel IVI clinics are run to enable sufficient registrar training.
Methods
Training standards and requirements
- The procedure must be performed by a registered nurse (RN) level 7 or above. Who must hold an ophthalmic nursing qualification or have sufficient ophthalmic experience to be determined by their manager as competent to commence training.
- The ICNC candidate, must have completed the intravitreal training course conducted through the Moorfield's Eye Hospital London or other accredited intravitreal injection training course. The study session must include a series of formal lectures on intravitreal injections, complications that can occur and personal study into risk and complications for the injection procedure.
- The nurse will not be signed off as a competent injector unless the supervising consultant is fully confident in the practitioner's ability to safely perform the role.
- Once the ICNC candidate has been deemed a competent intravitreal injector by an ophthalmology consultant, the ICNC will require authorisation to practice by the GCHHS nurse credentialing committee. Committee members will assess the signing off documentation of both disciplines of the ICNC and review consultant recommendation references of the potential applicant, along with reviewing the evidence of appropriate personal indemnity insurance of the ICNC of ophthalmology.
- The ICNC will have their competency assessed by the supervising consultant every three months in the first year to safeguard patient safety and monitor safe practice.
Interventional CNC Responsibilities
- The ICNC undertaking the advanced practice role is responsible for keeping up to date accurate training records and updating their injections records.
- Once training is complete and the ICNC is signed off as credentialed and competent to practice independently. The ICNC is required to audit their patient records every three months for the first year and yearly thereafter reporting on outcomes to the supervising consultant or designated deputies. Rigorous evaluation audits ensure that the nurse delivered injection service results in optimal patient outcomes and continual nursing education.
- The ICNC administering the injection has a duty of care to ensure that the patient that is being treated is fully informed of the risks and benefits of the injections. Patients have the right to refuse their treatment by the nurse if they have any concerns. Reasons for refusal must be clearly documented in the patient records.
Consultant Ophthalmologist's responsibilities
- Formally examine the ICNC to ensure they have the knowledge base required prior to being deemed competent.
- Progression to each stage of training will only be achieved once a consultant has assessed that competency has been achieved.
- Provide adequate time for the nurse to observe intravitreal injection technique and to subsequently supervise and assess the nurse's procedural skills.
Discussion
For the project to succeed, the ICNC role requires:
- reflective practice to perfect injection skills and supervisor feedback are essential in forming a better understanding of actions to develop improved skills through reflection on each step of the procedure
- continuous audits assessed by ophthalmology consultant at 3-month intervals investigating patient outcomes over the first year of independent practice
- supportive line manager, ophthalmologists, and nursing team members.
Benefits
1. Improved Access to Care:
- APNs can alleviate the burden on ophthalmologists by handling routine injections, freeing up specialist time for more complex cases or surgical procedures
- reduces patient wait times and improves service efficiency, especially in high-demand clinics.
2. Cost-Effectiveness:
- utilising APNs for stable patients can reduce costs compared to a model relying solely on ophthalmologists
- helps optimize resource allocation within healthcare systems.
3. Patient-Centred Care:
- APNs often have strong communication and holistic care skills, improving patient satisfaction and compliance.
- Continuity of care may be enhanced when patients consistently see the same APN.
4. High-Quality Outcomes:
- Studies (e.g., UK's Moorfield's Eye Hospital model) show APNs deliver safe and effective intravitreal injections with complication rates similar to ophthalmologists when properly trained.
5. Workforce Flexibility:
- Helps address workforce shortages in ophthalmology and meets the increasing demand for chronic eye disease management.
Limitations
1. Training and Competency Requirements:
- extensive training and certification are necessary to ensure safety, which may require significant time and investment
- competency must be rigorously assessed and maintained.
2. Regulatory Barriers:
- Scope of practice varies by region or country. In some jurisdictions, APNs may not be legally allowed to perform injections without direct supervision.
3. Clinical Risk and Liability:
- Despite similar safety profiles, any adverse event under an APN may face higher scrutiny.
- Clear guidelines and shared liability agreements are essential.
4. Interprofessional Tensions:
- Potential resistance from ophthalmologists or other team members who may perceive role encroachment.
- Requires cultural shifts and clear communication to foster collaboration.
Opportunities
1. Scalable Service Models:
- Particularly useful in rural or underserved areas where ophthalmologist availability is limited.
- Mobile or satellite eye clinics could be staffed by APNs to extend reach.
2. Integrated Care Pathways:
- APNs can be part of multidisciplinary teams managing chronic diseases like diabetes, integrating ocular and systemic care more efficiently.
3. Research and Innovation:
- APNs can lead or support research into outcomes, patient satisfaction, and cost-benefit analyses of the APN-led anti-VEGF model.
- Could also be involved in trial administration or post-injection follow-ups.
4. Career Development and Role expansion:
- Offers APNs a defined career path in ophthalmology, potentially improving job satisfaction and retention in nursing.
- APNs could extend their involvement in Ophthalmology.
References
1. Mark Crocker (CNC Ophthalmology) Sunshine Coast Hospital and Health Service (SCHHS)
2. Auckland DHB Ophthalmic Expanded Nurses Training and Competency Programme 2013
3. Bolme S, Austeng D and Gjeilo K H. Task shifting of intravitreal injections from physicians to nurses: a qualitative study. BMC Health Services Research 2021. https://doi.org/10.1186/s12913-021-07203-8
4. Capital Coast DHB Ophthalmic Nurse Expanded Practice Competency Framework 2017, Capital & coast district health board. 2017
5. DaCosta J, Hamilton R, Nago J, Mapani A, Kennedy E, Luckett T, Pavesio C, and Flanagan D. Implementation of a nurse-delivered intravitreal injection service. EYE, The Scientific Journal of The Royal College of Ophthalmologists. 2014 June vol28 number 6
6. Drury V. An integrative literature review of the effectiveness of nurse-led clinics in ophthalmology. Insight- the Journal of the American Society of Ophthalmic Registered Nurses April 2017, Spring 2017 p22-27.
7. Gallagher M, Introduction of a nurse-led intravitreal injection service in ophthalmology, British Journal of Nursing 2017, vol 26 n14 p 800-802
8. Guideline: Expanded practice for Registered Nurses, Te Kaunihera Tapuhi o Aotearoa, Nursing Council of New Zealand. May 2011.
9. Mc Donald E, Ram F. Seeing into the Future: ophthalmologists and specialist nurses working together, The New Zealand medical Journal 2016 Vol 129 N 1438
10. Moorfield's Eye Hospital Clinical Guideline for the administration of intravitreal injections of anti- VEGF medication for Macular disease by Nurse Practitioners- Moorfield's Eye Hospital NHS foundation trust. 2016.
11. Nago J, Intravitreal injections for nurse practitioners: A guide to good practice. International Journal of Ophthalmic Practice. 2015 Vol 6 n 1 https://doi.org/10.12968/ijop.2015.6.1.2
12. Queensland Health Delegated consent position statement, Nursing and Midwifery office, Queensland. October 2013 https://www.health.qld.gov.au/__data/assets/pdf_file/0022/156082/delegated_consent_pos_sta.pdf accessed May 2023
13. Royal Australian and New Zealand College of Ophthalmologists Guidelines for Performing Intravitreal therapy January 2023 Version 3.
14. The Royal College of Ophthalmologists (2013) College Statement on intra-ocular injections by non -medical health care professionals, press release, 1 May, 2013 http://www.rcophth.ac.uk/news.asp?section=24&itemid=1363&search
15. Varma D, Lunt D, Johnson P, Stanley S, A novel approach to expanding the role of nurses to deliver intravitreal injections for patients with age related macular degeneration. International Journal of Ophthalmic Practice. 2013 vol 4 n 2 68-74.
16. Wilson-Miller R, Stanley H, Nurse-led intravitreal injection clinic: defining the ophthalmic nurse's scope of practice and educational needs. International Journal of Ophthalmic Practice. 2014 vol 5 n 4.
Key contact
Canice Jeremiah and Carmen Newman
Interventional Clinical Nurse Consultant, Ophthalmology
Gold Coast University Hospital