PRE-ARCHITECT: Workflow, time-action, and patient experience of the current clinical practice of brachytherapy in patients with cervical cancer

Abstract

Introduction: The Erasmus MC and TU Delft started the ARCHITECT project to develop a personalized applicator design approach for performing brachytherapy in patients with cervical cancer.
Workflow for executing brachytherapy differs a lot between institutions.
An overview of the workflow was created and time analysis of the steps was performed to identify bottlenecks and points of improvement in the current clinical practice of brachytherapy in cervical cancer. This overview could also be used as a reference for future research.
Methods: An overview of the workflow was created, the time needed for the different steps was registered and patients were asked to fill out questionnaires on patient experience. The current clinical practice was observed to create the workflow overview and define the steps of which time should be registered. As some steps occurred in parallel the radiotherapy technicians, radiation oncologists and nurses were asked to assist in reporting of times. Matlab was used to calculate the duration of the steps and SPSS was used to determine the descriptive statistics.
The research protocol written for the patient experience study was approved but the medical ethics committee. Patients were informed on the study so they could provide informed consent.
The EQ-5D questionnaire was used to asses initial pain, anxiety and quality of life. A questionnaire on pain, anxiety and duration of each step during treatment day that was used for evaluating patient experience.
Result: A workflow overview per location was created. Data of forty implantations in fifteen patients were included for time analysis. The general steps and mean time needed for these steps were: operating room (55 minutes), waiting before arrival at imaging (80 minutes), applicator reconstruction (57 minutes), contouring (50 minutes), treatment planning (50 minutes), clinical physicist check (22 minutes) and treatment room (41 minutes). The mean total procedure time from patient entering the operating room until leaving the treatment room was 391 minutes.
The time needed for implantation of subsequent treatment fractions compared to the first treatment fraction decreased in sixteen out of the twenty fractions. The time needed at the operating room in patients receiving spinal anesthesia did not differ from patients receiving general anesthesia.
Four patients provided informed consent and filled out the questionnaires on patient experience. Patient experience differed a lot in these four patients. Overall, highest anxiety scores were found during the first brachytherapy day and highest pain scores were found during the waiting time at the short stay unit.
Discussion: The steps observed in the Erasmus MC did not agree on all steps that were found in literature. Time needed for these steps also differed when comparing to literature. The total waiting time could be decreased when enabling a more smooth transition between the recovery room and imaging step.
Adaptions to the time registration sheet should include the time needed for assembling the applicator at the operating room. The contouring step should be separated in contouring of the OAR and target volume. Time needed for imaging is not that important as the imaging protocol is the same in all patients. The decrease in waiting time for imaging when using the hyperthermia MRI should be evaluated. The influence of the amount of patients treated during one day would also be interesting to evaluate when more data has been collected. Another interesting factor would be differences in duration of the steps and pain experienced in patients treated with the Venezia applicator compared to the Utrecht applicator. More patients need to be included in the questionnaire study to draw conclusions on patient experience.