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Daily waiting time management for modern radiation oncology department in Indian perspective

1 Department of Radiation Oncology, MAX Superspeciality Hospital Patparganj and Vaishali, New Delhi, India
2 Department of Radiation Oncology, SCB Medical College, Cuttack, Odisha, India
3 Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Vishakhapatnam, Andhra Pradesh, India
4 Department of Radiation Oncology, Vardhaman Mahavir Medical College and Safdarjang Hospital, New Delhi, India

Date of Submission09-Oct-2020
Date of Decision01-Jan-2021
Date of Acceptance03-Jan-2021
Date of Web Publication03-Mar-2022

Correspondence Address:
Rashmi Shukla,
Department of Radiation Oncology, MAX Superspeciality Hospital, Patparganj and Vaishali, New Delhi - 110 092
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_1481_20

 > Abstract 

Introduction: Radiation therapy is one of the most technically sophisticated branch of medical sciences which caters to very ill patients, some of whom may be terminally ill. Since patients are treated on an outpatient basis which requires daily visit to hospital for a number of days, it can make them sensitive toward any increase in waiting time for their radiation treatment. This could be a source of stress for them. However, given the technical sophistication involved and varied clinical profile of patients, some amount of delay is inevitable.
Aim & Objective: To compile and suggest strategies to manage patient waiting time in Radiation oncology department to achieve optimum patient' satisfaction.
Method: The radiation oncologists in different institutes of the country were interviewed telephonically and were asked about the practices followed in their institutes/ departments in managing the patient waiting time during radiation treatment. The best practices being followed and the suggestions were compiled.
Conclusion: Now it is being recognized that meticulous management of waiting time could go a long way in driving patient's satisfaction. Twoway communications are the best strategy. Apart from this many provisions could be made in waiting area as per institutional preferences and protocol to engage patient in waiting area of radiation treatment facility

Keywords: Patient's satisfaction, radiation therapy, technical sophistication, twoway communication

How to cite this URL:
Gagan S, Padhi S, Patro KC, Shukla R, Shukla SK, Arora D, Singh TR, Kundu C, Bhattacharya P S, Krishna V, Madhur P. Daily waiting time management for modern radiation oncology department in Indian perspective. J Can Res Ther [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=339058

 > Introduction Top

Healthcare is one of the most important components of service sector of the economy. And the motto of service sector is customer's satisfaction. Similarly, the success of healthcare delivery system depends upon the satisfaction of the end user, i.e., the patients. Patient's satisfaction becomes even more important in the field of radiation oncology where terminally ill patients are also treated. As treatment with radiation is given 5 days a week on outpatient basis, patients become more conscious about the time spent waiting for the treatment. Any delay in the radiotherapy schedule would impact daily routine of the patients and cause more stress.[1] This in turn may impact the compliance of the patient affecting the clinical outcome. Hence, managing patient's waiting time meticulously is very important part of radiation treatment.

The field of radiation oncology is highly specialized branch of medicine involving radiation oncologists, medical physicists, radiotherapy technologists, and oncology nurses. Each of them has a defined role and responsibility to play in the treatment of cancer patients. Hence, the coordination among them is of utmost importance. Every day a number of patients are treated on RT machine of the radiation oncology department. All patients are provided with a time slot to avoid/minimize waiting time of the patient. However given the intricacies involved from planning to treatment, sometimes waiting becomes inevitable for the patients.

The factors causing increase in waiting time for radiotherapy treatment could be clinical, technical, and external.

 > Clinical Factors Top

The radiation treatment is very individualized. The protocols for treatment are site-specificrequiring individual set-ups. Even for the same site, each patient may have different clinical status and therefore requirements needing special considerations. These factors result inpatient spending longer time in treatment room.

The patient set-up on the treatment couch is generally very good for treatment for brain tumors. The errors are always very less[2] due to rigid anatomy. However, a higher number of the patients have poor performance status and therefore require more manpower to set-up for treatment. This requires a relatively longer time.

Head-and-neck cancer patient's setup with thermoplastic masks and individual head rests than other sites with use of the markings on the mask. This makes it efficient and less time consuming because the anatomy in this region is fairly consistent due to the natural prominent bony landmarks. However, majority of patients can suffer from Grade 3 mucositis by the end of 4 weeks[3] and majority of skin reactions develop at 20–40 Gy.[4] In these circumstances, the set-up time increases, especially if accessories such as mouth bites or bolus are being used.

For the radiation treatment of breast cancer patients, most centers do not use thermoplastic mold, and therefore matching the laser with skin markings may take more time for setup especially for patients with loose skin or who are overweight.[5] Understandably, treating left-sided breast with deep inspiratory breath hold (DIBH) takes longer time due to the need for respiratory synchronization.[6] Most patients take 3–4 days for respiratory coaching but still on the day of treatment they may take longer time to achieve a desired respiratory pattern due to an understandable anxiety and apprehension.

Patients receiving radiation therapy for lung cancers also require a longer time for set-up. The same is due to relatively lesser prominent bony landmarks in this region. The patients need to be set-up as per indexed markings on the patient's body. These patients may have been planned by using motion management techniques such as gating of breath hold techniques which take more time.[7],[8] Hence, generally it requires 30 min for conventionally fractionated treatment of lung cancer and 45 min for stereotactic body radiotherapy (SBRT) of lung cancer.

When we treat abdominal cancers with fractionated radiotherapy, set-up time can be long due to lesser bony landmarks. Furthermore, the patients may require specialized protocols for treatment such as empty stomach or motion encompassing techniques. The set-up is generally done using markings indexed with couch positions. Image-guided radiotherapy therefore can be particularly useful there.[9]

SBRT spine patients can take longer time for setup because of severe pain, cord compression, vertebral compression fracture, and more in cervicothoracic region where movement is more.[10] Best way to avoid this to give analgesics, anti-inflammatory before treatment. Patients with low-performance score requires additional manpower and support for getting to the couch. It generally takes 40–45 min for such patients.

Liver SBRT patients require a longer time for set-up and treatment. This is due to the use of motion encompassing techniques such as DIBH or four-dimensional computed tomography (CT).[11] Difficulties arise while treating the segment 1–4 near the stomach. Even with a period of 4 h fasting, a slightly distended stomach can come inside the planning target volume. This can add to the waiting period for a patient due to multiple time verification which is quite challenging. To solve this issue, we treat these patients after an overnight fasting as a first patient on the machine early morning.

Patients receiving radiation therapy to any pelvic site has its own issues. While every patient needs to follow bladder protocols for reproducible full bladders,[12],[13],[14] however, filling of the bladder also depends on general hydration in a particular day. Patients in later phase of their treatment may find it difficult to hold their urine. The patients with a heavy body weight can make alignment difficult during set-up due to relatively lesser prominent bony landmarks. The same may be countered using more accessories with thermoplastic mold.[15] Finally, due to the higher chances of rotational errors, patients receiving pelvic radiotherapy need to be frequently repositioned. Its better to keep a slot of 30 min for such patients.

Treating prostate cancer with hypofractionation or SBRT with full bladder, empty rectum with bladder and/or rectal protocol to minimize the toxicity is very challenging. The patient have to be repositioned again because of inadequacy of bladder rectal protocol and it prolongs the waiting time of other patients.[16]

Extremity sarcoma patients may also require a long time because they may have special/uncertain setups and may have edema and skin reactions during the course of treatment. Furthermore, alignment can be difficult due to a long target area.[17]

Therefore, it can concluded that the waiting time depends on the site of the tumor and the complexity of the treatment plan. It is better to keep an afternoon slot for pelvic malignancies since the incident issues pertaining to these may be better handled in the latter part of the day. This is because even if there are any delays due to bladder protocol, one patient may be adjusted during that time. We have found that breast patients may be best suited for the evenings as these cases do not get delayed and may not disrupt the roster of the technologists. As discussed before, SBRT takes longer time, so it is preferred to keep SBRT plan as separate slots.

It is advisable to schedule a gap of half an hour in every 3 h to reduce the cumulative waiting time to ease the build up of waiting time during the day.

The patients on rectal and bladder protocol must be provided with proper counseling.

Average expected treatment time in modern radiation department using daily imaging is described in [Table 1].
Table 1: Average expected treatment time in modern radiation department using daily imaging

Click here to view

 > Technical Factors Top

Since radiation treatment is given with sophisticated machines such as linear accelerator (LINAC) there is always a possibility of technical glitches in the form of breakdown. Parsons et al.[18] in their study found that the LINAC breakdown/downtime is the most common cause of treatment delay. It mostly occurs during the morning warm up and QA and may happen anytime of the day with aging of machine. These delays could be anywhere between 20 min and 150 min whether it could be resolved locally or by a field engineer.

A study by Wroe et al.[19] compared the LINAC breakdown in low-and middle-income countries (LMICs) than high-income countries. They analyzed from centers in Oxford (UK), Abuja, Benin, Enugu, Lagos, Sokoto (Nigeria), and Gaborone (Botswana). They deconstruct the linac into 12 different subsystems and found that the vacuum subsystem only failed in the LMIC centers and the rate of failure was more than twice as large in six of the 12 subsystems compared with the high-income country. They also found that inspite of total of 3.4% of fault, LINAC fault took >1 h to repair but include 74.6% of the total downtime.

Most of the centers in India are equipped with only one or two machines and it may not possible to shift patients from one machine to another because each of those may be full with their own patients. Therefore, these delays cannot always be compensated even where two machines may be available and leads to extension of treatment days sometime.

On the day of planning, there could be technical and functional issues with CT simulator which may cause delay in planning. Unavailability of certain accessories not available in duplicates could further delay the mold room procedure making the patient wait longer for radiation treatment. Therefore, we have multiple sets of accessories to minimize waiting time of patients scheduled for simulation.

Complex planning of Reirradiation, stereotactic radiotherapy (SRS), SBRT can take longer than usual time. Radiation Oncologists and Physicists may need more time for contouring and planning. Quality assurance for SRS and SBRT techniques also takes longer time. Additional time required, one to two days, for these activities compare to conventional treatment is accounted and explained to patient so that his waiting time on the day of treatment is minimal.

 > External Factor Top

There could be some external factors prolonging waiting time for the patient. This could be because of patient reporting late after their allotted time. The reasons for this could be numerous such as traffic jam, transport, and logistic issues. In a private set up there could be an issue with payment which could be from patient's end or from insurer's end. All these factors might result in increase in waiting time for the patients and more dissatisfaction.

Ways to manage the patient waiting room

Given the multitude of the factors involved in radiation treatment some amount of delay and prolonging of waiting time of some patients is inevitable and good briefing prior to start of treatment on this aspect prepares patient well receptive to changing situations. However meticulous management of waiting time of patients could result in higher satisfaction among the patients.

A study by Vieira et al.[20] studied pretreatment workflow of a large radiotherapy department of a Dutch hospital about scheduling of the first irradiation session. It was set right after consultation (pull strategy) or be set after the pretreatment workflow has been completed (push strategy). There was 12% lower average waiting times and 48% fewer first appointment rebooks using hybrid (40% pull/60% push) strategy. There was 21% reduction in waiting times by spreading consultation slots evenly throughout the week.

We can have different sets of strategies for different factors causing delay. Some of the suggestions are:

  1. First and foremost is establishing a healthy and assuring communication with the patient. Gesell and Gregory[21] in their survey outlined 28 priority actions to improve patients' satisfaction. Out of these 28 items, “staff sensitivity to personal difficulties and inconvenience” is ranked the most important and number one priority
  2. Not to review all patients same day. This could be achieved by dividing patients for review on different days. Only patients with complaints could be reviewed on any day
  3. Having limited discussion with the patients and attendants: All the patients should be explained about the radiation treatment and its predictable side effects before starting the radiation treatment. Once treatment is started discussion should be minimized during review days to avoid delay in treatment. Thus avoiding other patients from waiting
  4. All the patients should be advised to collect reports before reporting for review
  5. Patient on concurrent chemoradiation, should report for chemotherapy well in advance so that the chemotherapy gets over before the RT treatment slot of the patients. The co-ordination between radiation oncology team, medical oncology team, and the patient is very important
  6. It would be prudent to plan the patient before patient come to the department. Once treatment plan is finalized with everyone on board, then only patient should be called for the treatment
  7. In case of Linac breakdown patient should be informed on phone so that they don't have to come to the hospital and return back without treatment session. For patients who have already arrived for treatment, explaining and assuring them would be the right strategy. To remain engage with patients through phones would be more assuring during the period of breakdown. One staff could be deputed for this purpose
  8. To save the patient from waiting and to have substitute for the first one in case of breakdown Twin LINAC is the best idea. The beam data for both the machine is generated and adjusted in a comparable way. The same beam data model is used for both machines reducing the calculation time and same plan can be used on second LINAC. If there are a breakdown and vice versa. There will be only one set of quality checklist including tolerance value reducing the time and efforts for commissioning and quality assurance. Thus, giving the satisfying results and reducing patient waiting time in case of breakdown[22]
  9. An experienced and well-trained team can handle complex treatments efficiently with great patient satisfaction. Institutes should invest in training of involved staff at all levels for high performance.

Apart from the above strategies, engaging patients and attendants during waiting time can also play a big role in driving patient's satisfaction.

The patient's comfort and satisfaction should be kept in mind while planning and designing the waiting room. The seating arrangements and lighting along with sound system should be done so as to predict patient's satisfaction and experience of pain.[23],[24] Longer the waiting lower is the patient satisfaction.

However, by keeping them occupied during the wait, their satisfaction could markedly be increased, even if the waiting time remains unaltered.[25] For this certain provisions can be made in the waiting area:

  1. A facilitator or co-ordinator could be appointed for communication with the patients in waiting area. Few words from hospital staffs could be very assuring to the patients and will lessen their anxiety and apprehension
  2. Provision for engaging patients in the waiting area in the form of some light indoor activity would be very refreshing and entertaining for the patients and their attendants. At same time this would give them opportunity to interact among themselves and share their experiences
  3. TV screens with news, spiritual some light music could be truly engaging. Recorded messages from cancer survivor would make the patients and their attendants more positive and receptive towards their illness and treatment
  4. A small reading corner could be created with tables and chair with some reading stuff like newspapers, magazines, books etc., Books with pictorial messages could be very engaging and impressive
  5. AV videos and information booklets with information about side effects of radiation treatment on different sites and how to overcome it should be displayed. It makes the work of counsellor easier
  6. Some information regarding rehabilitation in cancer survivors could be very interesting. It is the loss of function that decreases the morale of the cancer patients. Any video demonstration showing them near normal life post cancer treatment could have the most positive psychological impact on the patients and their relatives.

 > Conclusion Top

These are some of the measures that will help enhance patient satisfaction and avoid stress arising out of prolonging of treatment time. Different institutions might have their own protocol for managing such issues, but two-way communication is the most effective tool when it comes to assuring anxious patients. However, there are not many studies conducted on the effect increased of waiting time on patient's satisfaction and literatures are scarce. A scientific study of different aspects of delay or prolonging of treatment waiting time for radiation treatment will go a long way in dealing with this important issue concerning radiation oncology.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

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