Training to insert Implanon

Transcription

1 12 Learning from each other Training to insert Implanon To increase the uptake of long-acting reversible contraceptive methods, there is an urgent need for more health professionals to be trained to insert Implanon. The author provides an up-to-date explanation of the training routes available, for both doctors and nurses. Dr Deborah J. Lee, MFFP, MRCGP, DRCOG, Dip GUM, Dip Colp, LOC Med Ed, Locum Consultant in Reproductive Health, Salisbury District Hospital, Wiltshire. This is an update of an article entitled Implanon training: getting things straight?, published in this journal in Implanon has been available in the UK as a form of contraception for women since It is a small, latex-free rod, 4cm long and 2mm wide, approximately the size of a matchstick, which is inserted subdermally into the upper, inner aspect of the non-dominant arm (Figure 1). Once in situ, a low dose of the progestogen etonogestrel is released in a controlled fashion, via a rate-limiting membrane. The main mechanism of action is to inhibit ovulation by specifically inhibiting the luteinising hormone surge. This is important clinically, as follicle-stimulating hormone levels are in the normal range, and oestrogen levels remain within those of the normal range for the early follicular phase of the cycle. Once fitted, Implanon can be left in situ for three years, and as there are very few drug interactions, the device is considered a fit and forget method of contraception. Implanon has the lowest failure rate of all methods of contraception. If 1000 women used Implanon for three years, there would be less than one pregnancy. 3 It is suitable for a wide variety of patients. As a progestogen-only method, it is for women for whom oestrogen methods are contraindicated, such as those aged over 35 years who smoke, those who have a body mass index over 40, or those who have a past history of venous thromboembolism. Because it can be fitted and forgotten, it is a good choice for women who, for example, find remembering pills difficult. As our most efficacious method of contraception, it may be a good choice for women who have had unplanned pregnancies. As it does not affect bone mineral density, it is a popular option as an alternative to Depo-Provera for women who have risk factors for osteoporosis. As a long-acting reversible method of contraception (LARC), the use of Implanon has been endorsed by NICE in its 2005 guidelines. 4 There are few contraindications to the use of Implanon. The device should not be used in women taking enzyme-inducing drugs. Care must be taken not to fit the device in women in the early stages of pregnancy. For the full list of eligibility criteria, see the UK Medical Eligibility Criteria for Contraceptive Use on the Faculty of Sexual and Reproductive Healthcare (FSRH) website. 5 To increase the uptake of LARC methods, there is an urgent need for more health professionals to be trained to insert Implanon. To this end, facilitating uptake of Implanon training is vital. Doctors need to understand how to obtain this training, and how to maintain their Figure 1. Implanon is inserted subdermally into the upper, inner aspect of the non-dominant arm. experience. Specialist nurses are now able to acquire these skills too. Full information about progestogen-only implants is available from the Clinical Effectiveness Unit (see the Faculty website). 3 Who fits Implanon? Patients can choose whether to visit their GP for Implanon insertion, or whether to attend a contraception and sexual health (CASH) clinic. The device is usually inserted by a GP with a special interest in contraception and reproductive health, a CASH doctor, or sometimes a CASH nurse specialist. It may also be fitted by gynaecologists in hospital settings, such as under general anaesthetic at termination of pregnancy. Why does Implanon insertion and removal require special training? The insertion of Implanon requires special skills. Correct subdermal placement of the device is important for two reasons. First, the rod must be placed in a linear fashion (and not kinked) to ensure steady release of hormone. Second, with correct subdermal placement of the rod, the device should be simple to remove. Unfortunately, a very small number of devices (<0.1 per cent) are deep insertions, which are difficult to remove, and can result in delay in removal, scarring of

2 Learning from each other 13 the arm and psychological trauma. Correct insertion technique will ensure the device is easily palpable and straightforward to remove. However, there is a tendency to focus on the fitting/removal issues; it should be noted that the counselling skills in helping patients to choose and understand the relative advantages and disadvantages of Implanon are also very important. We are all expected to provide good medical practice as part of clinical governance. Providers of contraception s need to prove they are offering quality and value for money. Those inserting and removing Implanon need to be competent and safe for independent practice. They therefore need adequate training and to maintain their clinical experience. In-date DFSRH? Conventional training Contact local CASH Attend model arm and theory course Attend local CASH clinic for practical training Doctor wishes to insert/remove Implanon Community training Contact a CASH doctor who holds the LOC Med Ed and an in-date LOC SDI Arrange model arm and theory course in GP surgery with support from Schering-Plough CASH doctor attends a community Implanon clinic to supervise insertions and removals No in-date DFSRH? As for conventional or community training but Training to insert and remove Implanon The pathway for obtaining training in insertion and removal of Implanon is summarised in Figure 2. Observe one insertion Perform a minimum of two insertions under supervision Observe one insertion Perform a minimum of two insertions under supervision Getting started First, an interested practitioner must have had basic training in the field of contraception and sexual health. It is imperative that the doctor or nurse understands the context of Implanon as a method of contraception and uses the device appropriately. Training for doctors The basic qualification is the Diploma of the Faculty of Sexual and Reproductive Health (DFSRH), formerly the Diploma of the Faculty of Family Planning (DFFP). Full details of how to obtain the DFSRH are available on the Faculty website: Once the DFSRH has been obtained, the Letter of Competence in Subdermal Contraceptive Implant Observe one removal Perform a minimum of two removals under supervision Form Z/08 signed and sent to Faculty with fee LOC SDI obtained Valid five years Observe one removal Perform a minimum of two removals under supervision Form Z/08 signed and sent to Faculty with fee LOC SDI obtained Valid five years Form Z/08 signed but not sent to the Faculty for certificate CASH, contraception and sexual health; DFSRH, Diploma of the Faculty of Sexual and Reproductive Health; LOC Med Ed, Letter of Competence in Medical Education; LOC SDI, Letter of Competence in Subdermal Contraceptive Implant Techniques. Figure 2. Pathway for obtaining training in insertion and removal of Implanon.

3 14 Learning from each other Techniques (LOC SDI) may then be acquired. Details of LOC SDI training are again available on the Faculty website. There are two methods of obtaining practical Implanon training: conventional and community Implanon training. These will be considered separately. Training for nurses Nurses who are sufficiently experienced in contraception may undertake training to become independent Implanon inserters/removers. Details of training are available on the Royal College of Nursing website: www. rcn.org.uk. Nurses must have a recognised qualification in contraception and sexual health, and have been providing contraception to a minimum of 25 patients per week for a 12-month period within the past two years. They then have to attend an approved course and undergo a period of practical instruction in the same way as doctors. Nurse training also has to include training to administer local anaesthetics. Patient Group Directions for both Implanon and lidocaine are also available on the FSRH website. Model arm and theory course for doctors and nurses The first step for both doctors and nurses is to attend a model arm and theory course. These are run by most CASH s around the country, periodically, during the year. The local will be able to provide details of the next session. The trainer must be an instructing doctor who holds the Faculty training certificate, the Letter of Competence in Medical Education (LOC Med Ed). There is usually a charge for attending this session, set by the local. Alternatively, Schering-Plough, the manufacturers of Implanon, often run model arm and theory courses, and these may be arranged with the local pharmaceutical representative, often within a GP surgery. This training usually takes 1.5 hours and contains a presentation about the theoretical use of Implanon, such as its pharmacokinetics, the hallmarks of use, and all pertinent issues related to choosing and using the device, such as the relative advantages and disadvantages, counselling issues and how to manage side-effects, including irregular bleeding. Once this has been completed, all participants will undergo supervised instruction on how to insert and remove Implanon on a model arm. The Implanon training forms, needed by the doctors, can be downloaded from the Faculty website: form X/08 lists the eligibility criteria for training. Form Z/08 is the form needed to record attendance at the model arm and theory course, and subsequent clinical competencies. As with the DFSRH, there is a competency checklist (see form Z/08, page 2). All competencies must be achieved at least to level B to be safe for unsupervised practice. The trainer will sign the top of form Z/08 with the date of the model arm and theory session. The trainee then attends for practical training, by one of the methods described below. Conventional LOC SDI training for doctors Insertions: The trainee attends a clinical session within the CASH department. He or she will be allocated a primary trainer, who is a doctor with an in-date LOC SDI and an in-date LOC Med Ed. However, the practical training may be delegated to a secondary trainer, ie a doctor who has an in-date LOC SDI but not necessarily an in-date LOC Med Ed. The trainee observes one Implanon insertion, by the primary or the secondary trainer. He or she then performs a minimum of two insertions, under supervision, competently, to be certified as safe for unsupervised practice in insertion techniques. This is signed off on form Z/08 (at the top of page 3). For most trainees, two insertions are sufficient, but the instructor may ask for the trainee to do further insertions if he or she feels this is necessary to certify that doctor as competent. The final signing off on page 3 must be done by the primary trainer, who holds overall responsibility for the training. There is usually a charge for this training, made by the CASH department. Once a doctor has been certified as competent to insert Implanon, he or she may continue to fit the device, even though removal training has not yet been completed. Removals: Once the doctor has observed a minimum of one Implanon removal, and done a minimum of two removals under supervision, he or she will be certified, as described above, as competent for removal for safe unsupervised practice. Of note, the model arm and theory course and the practical training do not have to be provided by the same doctor. Form Z/08 can then be signed off and sent to the Faculty with the requisite fee, currently 35. Community LOC SDI training for doctors The trainee contacts a local doctor who is a Faculty instructor (ie holds the LOC Med Ed) and has an indate LOC SDI. This is the trainee s

4 Learning from each other 15 primary trainer. The same rules apply as above, regarding primary and secondary trainers. The trainee sets up an Implanon clinic in his or her own surgery, with patients who request insertion or removal of the device. The trainer visits the trainee in his or her own surgery, and supervises Implanon insertions on the trainee s own patients. In rural areas, where the trainee may have to travel long distances to attend an implant clinic within a local CASH (if indeed there is a dedicated implant clinic often there is not, especially in smaller s), this may be a more advantageous system. The cost of the trainer s time to conduct this training is covered by the manufacturer Schering-Plough. The same training forms are completed and the trainee has to pay the Faculty to obtain the certificate, as stated above. Setting up such a clinic is not usually difficult. The key issue is to ensure that patients continue with their current form of contraception until the date of the Implanon insertion. Removals are more difficult to do in this way, but can be obtained as and when they occur, either by the instructor visiting the surgery as required, or by the trainee accompanying the patient to the local CASH. The LOC SDI is valid for five years. When it is due for renewal, the following must be in place: each yearly Faculty subscription paid when due; recertification of primary qualification up to date; at least two hours of continuing education relevant to subdermal implants in the form of: lectures approved by the Faculty (quote approval number); courses/lectures provided by other organisations (evidence: certificate of attendance and programme); small-group work with the prior approval of a regional assessor (evidence: certificate of attendance and programme); reading of appropriate current publication(s), ie within the past five years (quote exact reference, author, journal, volume and page numbers); Completion of the Faculty SDI CD ROM (evidence: certificate). A log covering a consecutive 12- month period will need to be kept within 24 months of the date of recertification. This log will need to show a minimum of six procedures, to include at least one insertion and one removal. If the doctor has allowed the DFSRH subscriptions to lapse, he or she may rejoin the Faculty once, by special dispensation, without paying a backlog of subscriptions. Doctors who do not have a DFSRH Some doctors may have trained many years ago, had a Family Planning Certificate (FP Cert), have continued to see large numbers of patients for contraceptive issues, and wish to insert and remove Implanon. There are two options for these doctors, as outlined below. Option one Bite the bullet and do the DFSRH. The syllabus was altered in line with the 2001 National Strategy for Sexual Health and HIV, and includes a module on sexually transmitted infections. Most doctors who have done the training are glad that they have completed it and feel it has helped their everyday practice enormously. Training is competency-based and is organised with an initial assessment with the primary trainer to assess individual learning needs. The typical training pathway will mean, for example, the trainee attending a number of CASH clinics and one or two genitourinary medicine clinics. Experienced trainees will be able to fast-track their practical training with the sessions they do, and ensure these are focused on their particular learning needs. The trainee must be assessed a minimum of four times during training, with one being an initial assessment at the start of training, and one for summative assessment at the end of training. The other two meetings will be interim assessments to check on the trainee s progress. The important issue here is that the training is structured to give each trainee what he or she requires. Therefore, for those who are already experienced, acquiring the diploma is not as laborious as it may seem. The way in which DFSRH training is structured is changing; a new training schedule is starting in January Doctors will have to register with the Faculty, complete 20 hours of e-learning on line, attend a one-day course of 5 and then have a practical competency-based attachment with a local CASH. As the new system is phased in, trainees who have completed the DFSRH theory course in the preceding three years will still be able to complete their DFSRH, using the traditional route. Option two There is no regulation that all doctors must belong to the FSRH as diplomats or members. Hence for doctors who do not wish to go down the conventional route of acquiring the DFSRH and LOC SDI, there has to be an alternative option. These doctors are strongly recommended to make sure that they have been trained to a similar standard as their colleagues who have been certified

5 16 Learning from each other TEACHING POINTS: FOR NURSES The details of nurse training requirements to insert Implanon are on the RCN website: Nurses must have a basic qualifi cation in contraception and sexual health The nurse must be seeing a minimum of 25 patients for contraception per week (some nurses will require more) must be fi tted under the supervision of a Faculty Instructing doctor or an accredited nurse trainer (some nurses will require more) must be removed under the supervision of a Faculty Instructing doctor or an accredited nurse trainer The certifi cate is valid for fi ve years, and then needs to be recertifi ed For details, contact your local CASH in the traditional way, with an LOC SDI. This means being up to date with contraception and reproductive health, ie having ten hours in the past five years of continuing medical education pertaining to this field, of which two hours of education during this time should be specifically on the subject of contraceptive implants. These doctors should then undergo training in the usual way, as described above, with a qualified TEACHING POINTS: FOR DOCTORS Implanon insertion and removal is a specialist skill to be acquired after obtaining the DFSRH Details are on the website of the Faculty of Sexual and Reproductive Healthcare: The recognised certifi cate is the Letter of Competence in Subdermal Contraceptive Implant Techniques (LOC SDI) must be fi tted competently under supervision (some doctors will require more) must be removed competently under supervision (some doctors will require more) The certifi cate is valid for fi ve years, and then needs to be recertifi ed For details, contact your local CASH Faculty instructor, and fill in the training form Z/08; but once signed off as competent, they will not be able to pay the 35 and obtain the LOC SDI certificate. They can, however, produce their training documentation if they ever need to do so, to prove they have been adequately trained. Conclusions The article outlines how to obtain training to insert Implanon (see Figure 2). Doctors may obtain their training via either the conventional or community LOC SDI training route. It should be made clear that CASH s will train doctors who do not have an in-date DFSRH, but may be reluctant to do so, in the face of waiting lists for training and the fact that many doctors on these waiting lists do have an in-date DFSRH. Facilitating Implanon training is of great importance if we are to increase uptake of LARC methods across the UK. References 1. Lee DJ. Implanon training: getting things straight? Trends Urol Gynaecol Sex Health 2004;9(5): Summary of Product Characteristics. Implanon ( uk; accessed 8 January 2010). 3. Faculty of Sexual and Reproductive Healthcare. Clinical Effectiveness Unit. Progestogen-only implants, April 2008 ( accessed 8 January 2010). 4. National Institute for Health and Clinical Excellence. Long-acting reversible contraception: the effective and appropriate use of long-acting reversible contraception. Clinical guideline 30, October 2005 ( CG030fullguideline.pdf; accessed 8 January 2010). 5. Faculty of Sexual and Reproductive Healthcare. Clinical Effectiveness Unit. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC 2005/06). ( accessed 8 January 2010).