Nurse ‘Injectors’

The great demand for minimally invasive cosmetic procedures can complicate a plastic surgeon’s schedule by diverting time from surgical procedures that likely attracted him or her to the specialty in the first place.

To alleviate this crunch, some physicians are turning to nurses and other paramedical professionals to cover the mainstay of their injectables business.

Reasons for doing so include increasing practice revenue streams  and career advancement for the “nurse injectors.” It may also allow plastic surgeons to spend more time in the O.R. performing surgical procedures. Many plastic surgeons, however, believe such practices are taking the most popular aspect of cosmetic medicine out of the hands of physicians – and have the potential to create a new generation of liability and scope of practice issues.

Several organizations have recently begun to collect data on the number of nurses who focus their work on injections and fillers, and numerous sources say it’s apparent that the trend is growing. However, a recent survey conducted by the ASPS-ASAPS Cosmetic Surgery Alliance indicates that a vast majority of plastic surgeons still perform their own injections.

“The member survey shows that right now, 94 percent of the members are doing their own injections,” says CSA’s Cosmetic Medicine Task Force co-Chair Richard D’Amico, MD. “That’s not a statement on one side or the other of that debate – it simply says that, at the present time, physicians are preferring to do this themselves.”

As a growing number of physicians from other medical specialties are already venturing beyond their core training to offer injectables, fillers and other cosmetic procedures to patients, many plastic surgeons are wary of inviting a new scope of practice battle into their offices. And weakening the specialty’s efforts in battling existing ones.

“It wasn’t more than 10 years ago that internists were allowing nurse practitioners to see patients on their own – the offshoot of that was that nurse practitioners began opening their own offices by themselves with little to no medical supervision,” says ASPS Quality & Performance Measurement Committee member Scot Glasberg, MD, New York. “We could be setting ourselves up for the same type of thing. We continue to talk about the infiltration of the specialty by other physicians, but if we continue to give up the procedures that we do, other physicians and paraprofessionals are going to continue to take them away.”

“As plastic surgeons, we are constantly coming up against legislators who do not understand surgical practice and who have, in many states, assigned the responsibility of performing these procedures to people who have little or no training in those specific areas,” adds Geoffrey Keyes, MD, Los Angeles, a member of the AAAASF Board of Directors. “What some people consider an easing up on their busy schedules may ultimately become the loss of scope of practice.”

Not all plastic surgeons, however, share the notion that nurse injectors pose a competitive threat. James Yates, MD, Camp Hill, Pa., says that while there are worthy scope-of-practice battles that plastic surgeons can fight, this isn’t one of them.

“Nurses in hospitals and other facilities are allowed to inject medications that are more risky than fillers and other similar injectables – I’m referring to morphine, Demerol and other toxic medications that are injected without the direct supervision of a physician,” says Dr. Yates, AAAASF immediate-past president. “Botox® Cosmetic isn’t nearly as risky. If nurses are allowed to inject what are clearly more risky substances, why would plastic surgeons believe they could mount a successful scope-of-practice stand against fillers and the like? We shouldn’t circle the wagons on this one.”

ASPS President Roxanne Guy, MD, Melbourne, Fla., says she believes nurse injectors can be a valuable addition to a plastic surgery practice if the correct training steps are taken – and that the specialty as a whole can benefit from their presence.

“I personally believe that trained nurse injectors can bring a sizeable value-added component to practices that have incorporated injectables into their practice models,” Dr. Guy says. “Having said that, I must stress that, in my practice, every potential nurse injector absolutely must undergo rigorous training – courses and symposia, as well as hours of sitting with me as I go through the entire process of consultation, injection and follow-up care – before they are allowed to work on a patient. And when that time finally comes, I will be there to supervise them.

“When conducted in the proper manner,” she adds, “nurse injectors can help a practice and keep its patients satisfied and coming back for additional procedures.”

Questions of significance

Dr. Yates agrees that long periods of training and observation are essential for nurse injectors – and the main reasons why he feels comfortable allowing appropriately trained staff to administer injections.

“My nurse has dozens of hours of training, she’s been to several courses with me and she will go to the next new course, whenever that will be offered,” Dr. Yates says. “In addition, she and most of my nursing staff have watched me perform hundreds of injections.”

“Plastic surgeons must infuse personnel who aspire to be nurse injectors with their philosophy about the process as well as their experiences in performing the injections – that’s the most valuable training by a wide margin,” says Paul Vitenas Jr., MD, Houston. “This should be a six-month, hands-on process. I don’t think a nurse is capable of going to a weekend course and injecting the following Monday. Workshops are wonderful tools, but in order to have a complete understanding of injectables they have to be trained over an extended period. Otherwise they shouldn’t pick up a syringe.”

“With appropriate supervision and evaluation by the physician, nurses can perform the technical act of the injection, but to me, practicing medicine means evaluating the patient and performing and/or directly supervising the procedure,” says ASPS Health Policy Committee Loren Schechter, MD, Morton Grove, Ill. “A patient may not be a good candidate for an injection – they may benefit from another procedure, and that’s why we go to medical school and do our surgical training. It’s not that we have to do every bit of the work, but when patients are seeking a medical opinion, the evaluation or opinion should be performed by a physician.”

Questions remain, however, as to who is qualified to perform these minimally invasive procedures, under what level of supervision, and whether there is a need for regulation. Of particular concern are nurses who administer injections at medical spas where physician supervision may be minimal to non-existent. Further muddying the issue is that physician supervision can be loosely interpreted – especially since each state has its own standards for the qualifications necessary to perform certain medical procedures.

ASPS and ASAPS issued a joint statement in 2006 on guiding principles for the supervision of non-physician personnel in medical spas and physician offices (available in the “Medical Professionals” section of www.plasticsurgery.org by clicking on the “Policy Statements” tab under “Health Policy & Advocacy”) that states the “surgeon must maintain direct responsibility for all treatments delegated to an allied health practitioner.” Likewise, the American Academy of Dermatologists (AAD) issued a position statement in 2002 (amended in 2005) on “The Use of Non-Physician Office Personnel,” which says “(The) physician must directly supervise the non-physician office personnel to protect the best interests and welfare of each patient,” when the appropriate circumstances have been met to allow the physician to delegate “certain procedures and services to appropriately trained non-physician office personnel.” (To see the statement, go to www.aad.org and enter “position statements” in the search field at the top of the page.)

But several nurses interviewed for this article say they know of others who work unsupervised and many develop their own clientele within their practices.
It’s a situation that can be quite appealing to other physicians – both plastic surgeons and other specialists – looking to build an aesthetic practice in the area, not to mention lucrative for the nurse injector.

“Nurses do shop themselves around and there is a fairly good competition for a good nurse because they get patients who like them a lot and will go with them to another practice,” says California Society of Plastic Surgeons President-elect Debra Johnson, MD, Sacramento. “Of course, just because a patient likes you doesn’t mean they’re not going to sue you if they have a complication, and the medical board is going to come after you because you’re the one who is ultimately responsible for the treatment. If a nurse is working under your license and under a protocol that you have established in your practice or medical spa, the bottom line is that it’s your medical license at the top of the food chain.”

Liability and qualifications

The American Nurses Association, which represents 2.7 million RNs, issued its first Scope and Standards of Practice for Plastic Surgery Nursing in 2005, but there is no specific mention of injections. The American Society of Plastic Surgical Nurses (ASPSN), however, established a Nurse Injector Task Force in April 2007 and offers injectables workshops during its annual meeting.

Task force member Jill Jones, RN, CPSN, Atlanta, who also serves as president of Aesthetic Advancements Inc., which trains nurses in nonsurgical aesthetics, says her company has trained more than 700 nurses to administer injectables since 2004. Many other nurses receive training directly from drug and device manufacturers – so that number is likely a drop in the bucket.

“The efforts toward credentialing and qualifying this role are in the very early stages,” Jones says. “The task force’s objective is to organize a group of very successful and proficient nurse injectors to provide state boards of medicine with information regarding the longstanding history of safe and effective treatments being provided by nurses under the supervision of a physician, as well as develop a level of competency for nurse injectors.”

Earlier this year, the Kentucky Board of Nursing issued a draft advisory opinion on cosmetic and dermatological procedures performed by nurses in that state and is attempting to provide guidance, but not regulations, on the topic. Injectables are included within the scope of practice of both RNs and LPNs in that opinion.

Susan Wells, RN, Lexington, Ky., who began her nursing career in 1979 and currently spends about 50 percent of her time working with injectables, worries that the advisory opinion doesn’t go far enough in the level of experience that should be required of a nurse injector. The Kentucky advisory opinion also does not specify an exact location for the supervising physician, except that he or she must be either on the premises or available by phone.

“There ought to be a more formalized credential,” says Wells, who adds that she received training in administering Botox® Cosmetic injections from the manufacturer in 2004. “One of my concerns is when I see a doctor allowing an LPN to inject Botox® Cosmetic is that this person needs to have a level of education not lower than RN. And I would not endorse somebody doing this just out of school – they need a plastic surgery background first.”

Anita Vennekotter, RN, Houston, says that while she isn’t certain there is a need for a formal credentialing system, she advocates going through certification programs for each product.

“I had on-the-job learning and did attend some programs, but I think the companies need to develop certification based on knowledge and technique,” she says.

On-site necessity

Wells also stresses the importance of having a supervising physician on the premises. “There are medical spas where they are doing injectables and the supervising physician lives three counties away,” she says.

Dr. Johnson employs two nurses at her skin care center who inject Botox® Cosmetic and fillers – but not before the patients are seen by a physician. She notes that a supervising physician is also always on premises whenever the nurses are giving injections.

“We are always on site,” she says. “We don’t allow our nurses to inject when we are not there. We might be in the O.R., but that’s only 50 feet away.”

Dr. Yates says that, in his practice, only he will perform an injection on a new patient. After that, he will ask the patient if he or she would prefer him or the nurse injector – and nine times out of 10 the patient choses his nurse. However, in either event the injections are performed under his supervision, Dr. Yates adds.

Vennekotter adds that she has been performing injections full-time for four years and that she treats 10-15 patients each day. During that time, she has only had one complication – an allergic reaction to a filler. Other complications can include bruising, numbness, pain and, with Botox® Cosmetic injections, weakness of the upper eyelid. But in rare cases, anaphylactic shock can result.

Dr. Yates says he’s particularly concerned with the variables involved with fillers containing microspheres, which have the potential to cause blocked blood vessels and arteries. The solution: No one but him injects these substances. “The risk is too great to allow these injectables to be administered by anybody but me – my nurse injector will not do these,” he says.

“These are not benign procedures, they are not without risk and they are not without morbidity,” says Dr. Glasberg. “According to the ASPS/ASAPS Guiding Principles for Supervision of Non-Physician Personnel in Medical Spas and Physician Offices, the surgeon should be readily available. When a paraprofessional is doing a procedure, ‘readily available’ means that if there’s an emergency, an allergic reaction or something like that, a physician has to be there. It’s not something a nurse or PA can deal with other than temporarily in the first few seconds.”

Despite these concerns, most RNs doing this work are very happy with the role and say the physicians they work for seem to benefit. “It’s actually very complementary to the physician’s practice,” says Wells. “It’s not a disservice financially because you’re keeping those patients in the loop. Most patients come in for the injections of fillers or microdermabrasion and later ask about surgery.”

Is good business good medicine?

ASPSN member Eileen Slimm, RN, New Brunswick, N.J., has specialized in plastic surgical nursing since 1988. Beginning in 2000, the practice where she works established a room dedicated to injectables and other skin care. “The ‘room’ has escalated into a great business,” says Slimm, who typically performs six to eight injections per day.

Slimm says she began performing injections in 1997 when a product representative for a collagen manufacturer told her they were allowing nurses to do injections and offered training and certification. She later received certification in Botox® Cosmetic and other products. “I belong to ASPSN and always attend the injectables courses, and I find a lot of nurses are going into this field. I hear that many nurses are now teaching their doctors,” she adds.

“My doctors feel it’s important for them to be with surgical patients. They want to be in the O.R. doing facelifts, breast work, etc. The injectables side is a good adjunct to the practice – especially in today’s aesthetics market because even though you have a facelift, you’ll still have nasolabial folds and other creases and need these treatments to enhance the surgical work.”

Samantha Wolfersberger, RN, Camp Hill, Pa., says her work as a nurse injector for Dr. Yates translated into a 10 percent increase in overall revenue for the practice. Some practices provide a price break if a service is provided strictly by a nurse, but Wolfersberger says doing so lessens the value of the services in the patients’ eyes. She adds that she always takes an opportunity to inform patients of other services offered by the practice, so there’s little risk that the injection work will reduce the physician’s revenue-earning potential.

Dr. Schechter urges his fellow plastic surgeons not to lose sight of their role as physicians, however, while trying to generate more business.

“It’s not only about the money,” he says. “It’s about practicing quality medicine, and each and every practitioner has to decide what is right for them in terms of what that means. We all need to make a living, but we also all have to decide where we draw the line. Simply because it’s not surgery does not mean it’s not a medical procedure, and it should be evaluated appropriately by a physician.”

“Each paramedical specialty that becomes more involved in patient care starts to want to carve out an additional arena in which to practice,” adds Dr. Keyes. “The problem is they don’t have the broad spectrum of training or graduated responsibility to understand all of the ramifications involved in that specific task.”

Slimm, however, says qualified nurse injectors offer something busy physicians can’t: their time. Slimm says she spends about an hour with each patient and provides extensive product and procedural information.

“A nurse can give the patient their time, tenderness and empathy, and along with this undertake the necessary treatments,” she says. “A lot of times the doctors are busy and have limited time. Patients are very educated today and have 1,001 questions. And if it’s their first time, you have to hold their hands through it and then deal with post care.”

Make time, or a slippery slope?

While time is often a precious commodity in busy plastic surgery practices, Dr. Glasberg says he manages his schedule by grouping together minor procedures.

“I’ll have a day or an afternoon where I do nothing but fillers and Botox® Cosmetic,” he says. “One of the things that takes away from my consultation days is doing minor procedures, so I’ll also lump them together, but I won’t give them away.”

And with more non-plastic surgeons jumping into the cosmetic medicine fray every year, the notion of granting non-physicians permission to administer injectables or fillers seems counterproductive for a specialty constantly locked in scope of practice issues with other physicians.

“Clearly, before you get into the ‘MD vs. MD,’ this is ‘MD vs. non-MD’ – and non-MDs need to be supervised,” says Dr. Glasberg. “We need to think long and hard before we start to give away these procedures.”

And the trend is not likely to stop at injectables. Some physicians are teaching their paramedical personnel to do additional basic procedures, such as the removal of lesions.

“If you have somebody other than a plastic surgeon performing your parasurgical cosmetic procedures, it’s a slippery slope,” says Dr. Keyes. “Especially if they’re excising lesions – ultimately, excising an upper-lid skin-only blepharoplasty becomes less of a stretch for someone who has been excising skin lesions than for somebody who hasn’t been doing surgery at all. And legislators are not easily convinced of what the difference is. I’m not saying it’s wrong – it’s just food for thought.”

“That’s the future,” says Dr. Johnson. “If we don’t play the good guys now and say, ‘No, you cannot operate independently, yes, you have to work under a physician, and yes, the patients are our responsibility,’ I think it’s a battle plastic surgeons are going to fight unless we have a united front.”

Dr. Vitenas says plastic surgeons should make peace with the concept of a growing number of nurse injectors and concentrate on proper training in the event they will employ one.

“We enjoy a free-market economy, and the fact remains that nurses are already doing injections – that genie’s out of the bottle,” he says. “Train your nurse injectors well if you want them to perform injections, and then watch them closely and as a matter of routine. Welcome it – don’t fight it.”

Ultimately, the future of who will administer fillers and injectables resides with the physician.