Quality Improvement: Review of Palliative RT wait times at the VA

Purpose: To summarize the amount of time our veterans wait from referral to palliative radiation treatment and to identify bottlenecks in our current workflow to guide further quality improvement efforts.

Methodology: This is a retrospective review of patients who received 8 Gy in 1 fraction, palliative radiation at the Clement J. Zablocki VA Medical Center in the last 3 years. Clinical data was obtained from MOSAIQ and CPRS. Demographic data, radiation treatment parameters, and disease characteristics were collected for each patient. The sites of palliation were classified into five groups: bone, dyspnea, liver, lymph nodes, bladder. Date of referral was defined as either the date the patient was referred to our department by another provider or if they were an established patient, the date of their last appointment when decision for palliation was made. Hours the patients waited between SIM and treatment were calculated using the electronic signature in MOSAIQ.

Results: We identified 24 eligible patients. The median age was 75 (range 63-93). Bone metastases were the most common reason for referral followed by dyspnea. At analysis, 16/24 (66.6%) of patients had died. The average wait time from referral to treatment was 12.75 days. The average time from referral to consultation was 3.82 days. The average number of days from referral to CT SIM was 9.46 days. The average time spent waiting to receive treatment after CT SIM was complete was 80.17 hrs. (3.34 days). Of the patients who died, the average number of days from referral to death was 60 days.

Conclusions: This informative quality review study allowed us to identify bottlenecks within our current palliative radiation workflow. The total time from referral to treatment was on average 12.75 days. The greatest delay occurred from the decision-to-treat to the CT SIM, averaging 5.64 days, identifying the CT SIM as the bottleneck. This observation provides the basis for our proposed phase II study for resource optimization by using a new workflow for our palliative cases which would forgo the CT SIM. The workflow would entail placing the patient on the LINAC couch, obtaining a cone beam CT, identifying targets, and calculating a treatment plan based on generalizable age- and organ-derived electron densities.

References: Wong S, et al. Diagnostic computed tomography enabled planning for palliative radiation therapy: Removing the need for a planning computed tomography scan. Practical Radiation Oncology. November 10, 2020. https://www.sciencedirect.com/science/article/abs/pii/S1879850020302642.

Wong, R, ET AL. A One-Step Cone-Beam CT-Enabled Planning-to-Treatment Model for Palliative Radiotherapy-From Development to Implementation. International Journal of Radiation Oncology. Volume 84, Issue 3, 2012, Pages 834-840, ISSN 0360-3016, https://doi.org/10.1016/j.ijrobp.2012.01.025.

Blyth CM, Anderson J, Hughson W, Thomas A. An innovative approach to palliative care within a radiotherapy department. Journal of Radiotherapy in Practice. 2000;2(2):85-90. doi:10.1017/S1460396900000145