Providing a Safe and Effective Intravitreal Treatment Service: Strategies for Service Delivery

Figures & data

Table 1 Points to Consider for Effective Virtual Clinics; a Consensus View Based on the Experience of All Members of the Working Group

Redesign of Invitation-To-Appointment Letters	Patient Outcome Letters	Patient Information Leaflets	Nurse/Technician Triage for Comorbidities in Virtual Data Collection Clinics	Clarification of Management Practice and Key Performance Indicators
Explain to patients that an update of diagnosis may not be given on the date of attendance at a virtual clinic - specialists will review the data and then plan the next appointment.	May facilitate service tariffs (ie claiming reimbursement for virtual assessments). Outcome letters reassure patients with low-grade pathology that an urgent review is not needed. For example, patients that have been referred as fast-track nAMD but who actually have a low-grade epiretinal membrane (ERM), can be booked routinely into VR clinics.	Traditionally given out at baseline in most patient pathways. Patients in virtual clinics may have less time to ask questions and have reduced access to senior staff members. So patient information leaflets may need distributing frequently later on in the pathway. Patients need to understand the virtual clinic is no less rigorous than a face to face visit, Consider using a different term to describe these clinics eg Digital Assessment.	Helps to pick up problems that could impact on treatment, such as recent cerebrovascular accident (CVA) or ocular infection. Consider compiling a list of FAQs for nurses in these clinics. EPR can facilitate this if available. For example, symptoms of a recent CVA, signs and symptoms of conjunctivitis.	Virtual clinic staff are often re-deployed to face-to-face services to cover sick leave or peaks in activity. Consider protecting staff against this with a formal policy that might include locally agreed internal key performance indicators (KPIs) for virtual review timings. For example, 48 hours for data review from a virtual clinic event in order to protect reviewing staff.

Table

Clean room (as defined by the local Infection Control Team) requirements

Enclosed; Dedicated to deal with clean (non-infected) cases; Free from interruption Sufficient size to accommodate a patient couch or recliner chair Allow staff access both sides of the head Facilities for hand washing The ceiling should be non-particulate and floors washable Good illumination in the room and injection field must be good Ventilation, at least 10 air changes/hour. If less than this local risk assessment advised

Table

Scrubs	There is no evidence that scrubs reduce surgical site infection (SSIs). However, since the injector is required to perform a surgical scrub before IVT, wearing scrubs may be preferable to a plastic apron.
Sterile gloves	The injector must carry out a full decontamination hand scrub before performing IVT^Citation45 and use gloves to prevent direct transfer of any residual bacteria from the injector’s hands to the sterile field or surgical site.
Caps	Wearing head cover is useful in keeping small amounts of hair or airborne bacteria away from the operative site.^Citation46,Citation47
Masks	Publications from the US and RCOphth guidance recommend that masks are worn by the injector, since their face is quite close to the operative field and a greater proportion of bacterial growth from endophthalmitis cases due to intravitreal injections appear to consist of oral flora.^Citation44,Citation48

Box 1 A Delegated HCP Should Be Provided with Practical Training on

Preparation for injections

Aseptic technique, including cleaning the eye

Draping of patient

Insertion of eye speculum (directly observed)

Safety checks prior to injection

Drawing up injection

Marking injection site

Delivery of injection

Post-injection checks

Management of untoward incidents (eg paracentesis)

Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2008;(1):CD004288.

 Web of Science ®Google Scholar

Mastro TD, Farley TA, Elliott JA, et al. An outbreak of surgical-wound infections due to group A streptococcus carried on the scalp. N Engl J Med. 1990;323(14):968–972. doi:10.1056/NEJM199010043231406

 Web of Science ®Google Scholar

Friberg B, Friberg S, Ostensson R, Burman LG. Surgical area contamination–comparable bacterial counts using disposable head and mask and helmet aspirator system, but dramatic increase upon omission of head-gear: an experimental study in horizontal laminar air-flow. J Hosp Infect. 2001;47(2):110–115. doi:10.1053/jhin.2000.0909

 Web of Science ®Google Scholar

The Royal College of Ophthalmologists (RCOphth). Intravitreal Injection Therapy. London: RCOphth; 2018. Available from: www.rcophth.ac.uk/wp-content/uploads/2018/02/intravitreal-injection-therapy-august-2018-2.pdf. Accessed January 2019.

 Google Scholar

Pilli S, Kotsolis A, Spaide RF, et al. Endophthalmitis associated with intravitreal anti-vascular endothelial growth factor therapy injections in an office setting. Am J Ophthalmol. 2008;145(5):879–882. doi:10.1016/j.ajo.2007.12.036

 PubMed Web of Science ®Google Scholar