Workflow and efficiency in MRI-based high-dose-rate brachytherapy for cervical cancer in a high-volume brachytherapy center

PurposeWe report the clinical workflow and time required for MRI-based image-guided brachytherapy (MR-IGBT) of cervical cancer patients in a high-volume brachytherapy center with 10 years of experiences to provide a practical guideline for implementing MR-IGBT into clinical use.Methods and MaterialsWe recorded the time and workflow of each procedure step within the 40 consecutive ring and tandem applicator fractions of MR-IGBT by our multidisciplinary team. We divided the entire procedure into four sections based on where the procedure was performed: (1) applicator insertion under sedation, (2) MR imaging, (3) planning, and (4) treatment delivery. In addition, we compared the current procedure time to the initial procedure time when first implementing MR-IGBT in 2007–2008 via a retrospective review.ResultsMean total procedure time was 149.3 min (SD 17.9, ranges 112–178). The multidisciplinary team included an anesthesia team, radiologist, radiation oncologist, nurses, radiation therapists, MRI technicians, dosimetrists, and physicists. The mean procedure time and ranges for each section (min) were as follows: (1) 56.2 (28.0–103.0), (2) 31.0 (19.0–70.0), (3) 44.3 (21.0–104.0), and (4) 17.8 (9.0–34.0). Under current setting, the combined mean procedure time for MR imaging and planning was 63.2 min. In comparison, the same procedure took 137.7 min in 2007–2008 period, which was significantly longer than the current workflow (p < 0.001).ConclusionsA skilled and dedicated multidisciplinary team is required for an efficient clinical workflow and delivery of MR-IGBT. Over the years, we have improved efficiency with clinical experience and continuous efforts in staff education.     

Order Entry Protocols Are an Amenable Target for Workflow Automation

PurposeOrder entry protocol selection of advanced imaging studies is labor-intensive, can disrupt workflow, and may displace staff from more valuable tasks. The aim of this study was to explore and compare the behaviors of radiologic technologists and radiologists when determining protocol to identify opportunities for workflow automation.MethodsA data set of over 273,000 cross-sectional examination orders from four hospitals within our health system was created. From this data set, we isolated the 12 most frequently requested examinations, which represent almost 50% of the entirety of advanced imaging volume. Intergroup comparisons were made between behavior of radiologic technologists and radiologists or residents when determining protocol. Frequencies of changes were calculated. Common parameters of changed examinations were identified.ResultsThe overall change rate for both radiologists and residents (4%) is very low and comparable to the overall change rate of radiologic technologists (1%). The change rates for the 12 most ordered examinations were calculated and compared individually. Most examinations that underwent change involved a patient with a low estimated glomerular filtration rate, a patient with a contrast allergy, or a provider ordering a general examination but in fact wanting an organ-specific protocol or an angiographic study.ConclusionOrder entry protocol selection of the most frequently ordered advanced imaging examinations was rarely a value-added activity because these examinations are rarely changed. Changes follow predictable patterns that make order entry protocol selection of most radiology orders for advanced imaging amenable to workflow automation.     

电子射野影像仪与锥形束CT用于胸部肿瘤 影像引导放疗的比较研究

目的 比较电子射野影像仪(EPID)和锥形束CT(CBCT)用于胸部肿瘤影像引导放疗,在工作流程和发现患者摆位误差两个方面为临床选择不同影像引导放疗工具提供依据。方法 选择2007年3月至2008年1月在我院接受根治性放疗的17例胸部恶性肿瘤患者(包括肺癌、食管癌和胸腺瘤),每位患者每周分别行千伏锥形束CT(KVCBCT)和EPID影像引导分析各1次。1例患者(肺癌)在完成2次KVCBCT在线引导放疗后自动退出研究,共有16例患者进入最终研究分析。结果 16例患者共获取81对EPI和CBCT影像。采用CBCT引导放疗系统时,患者的治疗总时间较采用EPID引导放疗系统时增加1.2 min。采用EPID引导放疗技术分析胸部肿瘤患者的摆位误差,患者在左右(LR)、头脚(SI)和前后(AP)3个方向上的摆位误差分别为:(-0.1±3.2)mm、(1.3±3.7)mm和(-0.2±3.1)mm。计算临床靶体积(CTV)到计划靶体积(PTV)的预留边界,CTV到PTV的预留边界应设定为10mm。采用KVCBCT引导放疗技术分析这部分患者的摆位误差,LR、SI和AP 3个方向上的摆位误差分别为:(0.1±4.6)mm、(0.6±4.0)mm和(-0.9±4.6)mm,CTV到PTV的预留边界应设定为12mm。结论 与EPID相比,采用CBCT引导放疗系统没有明显延长治疗时间,但增加了发现摆位误差的能力,建议有条件的单位选择CBCT进行胸部肿瘤患者的影像引导放疗或摆位误差分析。     

From mothership to drip-and-ship: Effects of staff shortages at a comprehensive stroke center

BackgroundMechanical thrombectomy (MT) has been shown to be effective in the acute phase of ischemic stroke. Current data suggests that the drip-and-ship and mothership telestroke models are equally effective for its administration. We describe the consequences of changing the telestroke model due to staff shortages in a comprehensive stroke center (Besançon), which was replaced by a more distant one (Dijon).MethodsWe conducted a retrospective analysis of all patients referred for MT from January 2015 to December 2018. We analyzed the time between symptom onset and arrival in the angiography suite. We also calculated number of thrombectomies divided by number of days on call, and rate of thrombectomies relative to the number of strokes in each group.ResultsIn Besançon, 205 patients underwent an MT procedure, versus 43 patients in Dijon. A further four patients were transferred to Dijon but not treated. The time from symptom onset to arrival in the angiography suite was longer for Dijon; 334 min versus 281 min for Besançon (p < 0.001). The percentage of thrombectomies performed per day on call was higher for Besançon: 18.6% versus 13.2% in Dijon (p = 0.026).ConclusionsOver the study period, the time from symptom onset to angiography suite was longer for patients who were transferred to Dijon. The period in which the Besançon hospital experienced the greatest lack of personnel corresponded to a decrease in the number of MTs performed.     

Improving Radiologist-IT Staff Communications and Collaboration Through a Shadowing Project

It is important for radiology practices to have efficient and skillful IT staff to provide support for issues that arise during patient care. However, an anecdotal barrier exists between radiologists and IT staff that can hinder the delivery of this care, either by lengthening the time required to solve problems with the IT infrastructure or not bringing critical issues to the IT staff’s attention. We first created a survey of the radiologists and IT staff in our department to investigate this barrier, and found that there was, at baseline, a significant difference in how one group viewed the other, and, at times, there were irrational expectations from either party of what their counterparts were responsible for or capable of. We then instituted a shadowing project, whereby radiologists shadowed IT staff and vice versa, in order to give each group a better understanding of the others’ daily workflows. We gave the participants a post-intervention survey to assess their experiences, which were markedly positive. In one case, an IT issue regarding pre-fetching of cardiovascular studies was, in fact, solved during the shadowing session.     

Primary care workflow process mapping of medication-related activities performed by non-provider staff: A pilot project's approach

BackgroundA workflow process mapping approach was previously developed to understand the impact of primary care medication use processes on medication safety. The workflow process mapping approach was applied to a pilot project in one primary care practice.ObjectivesThe objective of this article is to: (1) exemplify how workflow process mapping was implemented in one primary care practice to characterize medication safety issues (i.e., critical workflow gaps/deviations), (2) discuss the identified critical medication safety workflow gaps and deviations, and (3) summarize the pragmatic, practice-level recommendations developed to enhance practice-level medication safety.MethodsFour medication-related activities were directly observed, including: (1) medication reconciliation, (2) warfarin medication management, (3) vaccination administration, and (4) medication renewal requests. Observations occurred with registered nurses, medical assistants, and telephone operators. An ideal-state and observed workflow process map was created for each medication-related activity and was compared to identify critical medication safety workflow gaps and deviations. Practice-level recommendations were developed to enhance workflow and medication safety across all medication-related activities.Results111 medication-related observations were recorded over 6-weeks across all 4 workflows (100 observation hours). A total of 17 critical workflow safety gaps, 9 critical workflow step deviations, and 9 workflow sequence deviations were identified. Seventy-six percent of total workflow gaps resulted from inappropriate medication verification. Most workflow step deviations (33%) were due to inappropriate documentation, whereas most sequence deviations (44%) stemmed from inadequate medication verification. Practice-level recommendations to enhance warfarin medication safety were prioritized and implemented prior to the completion of the pilot project.ConclusionThe results of this workflow mapping pilot project exemplify the need to enhance primary care medication safety for workflows conducted by non-provider staff members in primary care practices. Additionally, this approach can be used to identify opportunities for primary care pharmacist integration, particularly for practices with little or no prior pharmacist involvement.     

Identifying impact of software dependencies on replicability of biomedical workflows

Complex data driven experiments form the basis of biomedical research. Recent findings warn that the context in which the software is run, that is the infrastructure and the third party dependencies, can have a crucial impact on the final results delivered by a computational experiment. This implies that in order to replicate the same result, not only the same data must be used, but also it must be run on an equivalent software stack.In this paper we present the VFramework that enables assessing replicability of workflows. It identifies whether any differences in software dependencies among two executions of the same workflow exist and whether they have impact on the produced results. We also conduct a case study in which we investigate the impact of software dependencies on replicability of Taverna workflows used in biomedical research of Huntington’s disease. We re-execute analysed workflows in environments differing in operating system distribution and configuration.The results show that the VFramework can be used to identify the impact of software dependencies on the replicability of biomedical workflows. Furthermore, we observe that despite the fact that the workflows are executed in a controlled environment, they still depend on specific tools installed in the environment. The context model used by the VFramework improves the deficiencies of provenance traces and documents also such tools. Based on our findings we define guidelines for workflow owners that enable them to improve replicability of their workflows.