Clinical Workflow

One of the most critical and under-discussed aspects of a radiation therapy program is a high-quality clinical workflow. Clinical workflow broadly encompasses every step within a radiation oncology department, from initial consultation to discharge and follow-up. An efficient clinic carefully considers its care paths and implements methods to optimize resources and manage risk.

Roles and Responsibilities

One area of optimization is role specialization and clearly defining responsibilities for each role. Depending on the clinic, physicist, dosimetrist, and physician roles can overlap, and practice standards vary widely. For example, according to a 2016 survey regarding prescriptions, the physician enters the prescription information in the electronic chart 58.1% of the time. For the remaining 41.9% of clinics, this responsibility falls on the dosimetrist. When creating a PTV from the GTV/CTV, the field is split: 50% of the time, the physician generates the structure, and 50% of the time, the dosimetrist does.

The lack of consensus on some clinical responsibilities demonstrates the variety of solutions for optimizing clinical roles. There is variation in treatment planning as well. Physicists tend to perform plans on more complicated special procedures. Treatments such as TBI, HDR, SRS, and Prostate Speed Implant are performed by physicists 87.8%, 77.4%, 67.3%, and 73.9% of the time, respectively. More common procedures like image fusions and SBRT were done by dosimetrists 93.0% and 73.1% of the time.

At Your Center, Who Routinely Does the Following?

Linac Scheduling

Optimization involves maximizing resource management. In a busy department, throughput is an important metric to consider. While the first patient visit is typically longer to accommodate patient education and proper setup, a 2015 survey found that most departments—80.3%— schedule routine appointments in a 15 minute time window. For the first fraction, 75.3% of respondents reported that a 30-minute time slot is best. Of course, for more complicated treatments such as SBRT, SRS, or multiple sites, appointment times may be necessarily longer. On average, most clinics aimed to treat 26 patients a day per linac.

Treatment After Hours

After hours palliative radiotherapy is sometimes necessary for emergent patients. A majority of departments—90.6% according to a 2015 survey—rely on staff to be available for occasional urgent need cases. For most radiation oncology programs, survey responses indicated that cord compression, SVC syndrome, excruciating bone metastasis, rectal bleeding, or whole brain cases were considered emergent. On-call service was expected from physicians and therapists, according to 95.9% of respondents. The expectation was slightly lower—80.8%— for dosimetrists creating the plan. In general, these cases were rare, with most clinics treating ten or fewer emergent patients a year. When the clinics did not offer after-hours radiotherapy, they were referred to another facility 20.0% of the time and treated the next clinical day 80.0% of the time.

Clinical Impact of COVID-19

Covid-19 was incredibly disruptive to the healthcare environment in 2020. With hospitals reeling to control transmission and the massive influx of patients, administrators put elective procedures on hold. Telework services boomed as workforces worldwide attempted to adapt by implementing remote systems and rotating in-person schedules. In radiation oncology, the efforts were similar. When polled at the end of March 2020, 79.1% of clinics had already allowed physicists to begin working from home and 78.7% allowed dosimetrists. The remaining 20.9% consisted primarily of smaller practices or sites that developed a rotating schedule of on-site physicists coupled with reduced patient volume.

Some clinicians were already doing some work from home prior to the pandemic, but COVID-19 forced the issue for a huge number of physicists and dosimetrists. Managing this new environment was a challenge for administrators and IT, juggling scheduling and productivity, technological hurdles and PHI.

Survey responses on the impact of COVID-19 showed a mutual appreciation for fellow colleagues. When physicists were asked if COVID-19 would change their clinics’ work-from-home policies, 53.1% believed it would have no future effect. Others (32.7%) thought it would, and 14.3% were unsure. Regardless of one’s stance on remote work, COVID-19 has fundamentally shifted the conversation on the ability to operate with remote staff, at least temporarily.

New Program Caseload

When expanding clinical services to offer a new treatment type, it’s important to consider the potential volume for that particular modality. In order to obtain and maintain the skill level required for special procedures, a minimum case level ought to be considered.

In a survey inquiring about the minimum caseload for SRS, SBRT, prostate seed implants (PSI), and HDR, physicists generally agreed that between 21-25 cases per year (an average of free responses) was required to maintain a high-quality program. The rationale provided in the comments involved generating enough revenue to cover costs as well as developing a strong familiarity with the treatment modality.

Suggested Minimum Caseload Required When Introducing A New Treatment Type

Physical Presence at SRT Procedures

Another factor to consider when adding treatment offerings is staffing resources. Special procedures require a higher level of oversight from physicians and physicists. Treatment modalities such as SRS, SBRT, and SRT feature high fractional doses and tight tolerances.

In a survey specific to SRT, 73.0% of respondents noted their facility required the physicist present for the entire first fraction. Some departments, 16.9%, required presence until setup was confirmed, and others wanted physicists to be “available in the department,” or had no requirement for physicist presence.

In contrast, only 37.0% of respondents required a physician to be present for the entire treatment, with 54.3% opting to include them for the setup only.

For subsequent fractions, the requirements for presence during the entire treatment dropped for both the physicist and physician to 46.6% and 20.7%, respectively. Most departments only required they be available or be present at the setup.

Physical Presence Requirements for SRT Procedures