Marianne Jackson

Quantitative assessment of workload and stressors in clinical radiation oncology

PURPOSE Workload level and sources of stressors have been implicated as sources of error in multiple settings. We assessed workload levels and sources of stressors among radiation oncology professionals. Furthermore, we explored the potential association between workload and the frequency of reported radiotherapy incidents by the World Health Organization (WHO). METHODS AND MATERIALS Data collection was aimed at various tasks performed by 21 study participants from different radiation oncology professional subgroups (simulation therapists, radiation therapists, physicists, dosimetrists, and physicians). Workload was assessed using National Aeronautics and Space Administration Task-Load Index (NASA TLX). Sources of stressors were quantified using observational methods and segregated using a standard taxonomy. Comparisons between professional subgroups and tasks were made using analysis of variance ANOVA, multivariate ANOVA, and Duncan test. An association between workload levels (NASA TLX) and the frequency of radiotherapy incidents (WHO incidents) was explored (Pearson correlation test). RESULTS A total of 173 workload assessments were obtained. Overall, simulation therapists had relatively low workloads (NASA TLX range, 30-36), and physicists had relatively high workloads (NASA TLX range, 51-63). NASA TLX scores for physicians, radiation therapists, and dosimetrists ranged from 40-52. There was marked intertask/professional subgroup variation (P<.0001). Mental demand (P<.001), physical demand (P=.001), and effort (P=.006) significantly differed among professional subgroups. Typically, there were 3-5 stressors per cycle of analyzed tasks with the following distribution: interruptions (41.4%), time factors (17%), technical factors (13.6%), teamwork issues (11.6%), patient factors (9.0%), and environmental factors (7.4%). A positive association between workload and frequency of reported radiotherapy incidents by the WHO was found (r = 0.87, P value=.045). CONCLUSIONS Workload level and sources of stressors vary among professional subgroups. Understanding the factors that influence these findings can guide adjustments to the workflow procedures, physical layout, and/or communication protocols to enhance safety. Additional evaluations are needed in order to better understand if these findings are systemic.

Unanticipated hospital admissions during or soon after radiation therapy: Incidence and predictive factors

PURPOSE Unplanned hospital admissions in cancer patients undergoing treatment is an understudied area with important implications for both health care costs and patient outcomes. The goal of this retrospective study was to evaluate the rate, reasons for, and predictors of unplanned hospital admissions during or soon after palliative or curative radiation therapy for cancer, with or without chemotherapy. METHODS AND MATERIALS A total of 1116 consecutive patients who received external beam radiation therapy for a malignancy at the University of North Carolina at Chapel Hill from January 1 through December 31, 2010, were studied. The primary outcome was unplanned hospitalization within 90 days of starting radiation therapy (ie, during or soon after). Multivariable logistic regression was used to examine patient and treatment factors associated with admissions. RESULTS Twenty percent of patients experienced an unplanned admission, which was especially likely in patients with lung (25% of such patients admitted), head and neck (22%), and gastrointestinal (21%) cancers, as well as those treated with palliative intent (31%). The most common causes for admission were gastrointestinal symptoms, neurologic symptoms, respiratory symptoms, pain, and fever or infection. Forty-seven percent of admitted patients were seen in the clinic within 2 weeks of unplanned hospital admission, and 61% of those patients had a related complaint in the clinic. Multivariate analysis showed that married patients (odds ratio [OR] = 0.58; P < .001), curative intent (OR = 0.38; P < .001), and no concurrent chemotherapy (OR = 0.55; P < .001) were associated with decreased odds for admission. CONCLUSIONS Unplanned admissions are relatively common during or soon after radiation therapy in our patient series. Additional work is needed to gather data from other centers and to better understand, and hopefully reduce, these unplanned admissions.

Unanticipated hospital admissions in patients undergoing radiotherapy with or without concurrent chemotherapy: Incidence and predictive factors.

114 Background: Unanticipated admissions are burdensome for patients and the healthcare system. An improved understanding of their frequency and predictive factors can inform initiatives to prevent such admissions and mitigate their associated human and financial costs. METHODS Electronic medical records of all patients (n=1144) undergoing external beam radiotherapy (RT) at our center in 2010 were reviewed in this retrospective study. Unanticipated admission within 90 days of initiating RT, and associated clinical factors, were recorded. Chi-squared and uni- and multivariate logistic regression was used to examine factors associated with admission. RESULTS Unanticipated admissions occurred in 19% (213/1144) of patients, median length of stay was 3 days (range 1-22), and the mean interval between the start of RT till admission was 28 days (1-89 days). The most common indications for admissions were pain (19% of admissions), GI toxicity (18%), and respiratory distress (15%). On univariate analysis, admission rates were higher in patients treated with palliative vs. curative intent (30% vs. 14%, p<0.001), with concurrent chemotherapy (23% vs. 18% RT alone, p=0.047), in those who had a recent admission prior to RT initiation (37% vs. 14% with no prior admission, p<0.001), and patients on their second or third course of RT (27% vs. 16% first treatment course, p<0.001). Multivariable analysis showed treatment intent, chemotherapy, and prior admissions to be associated with unplanned admissions (Table). CONCLUSIONS Rates of unanticipated admissions are ≈20% in patients undergoing RT. Slightly less than 1/3 of patients receiving palliative RT, and nearly 1/4 receiving concurrent chemoradiation, experienced an unplanned admission. Prophylactic measures should be studied in these high-risk patients to reduce admission rates, as unplanned admission may be an important quality of care indicator in oncology. [Table: see text].

Empirical Evaluation of Workload of the Radiation Oncology Physicist During Radiation Treatment Planning and Delivery

In recent years, the practice of radiation oncology has changed due to several technological advances. As such, there is growing interest in the evolving nature of safety and operational challenges faced by radiation oncology professionals. This research focuses on physicists who play an important role in the radiation therapy treatment planning and delivery process. Specifically, the purpose of our research is to assess their workload levels using the NASA TLX method in order to identify tasks that might compromise patient safety. Based on empirical observations, this study provides practical suggestions for lowering workload levels that ultimately can reduce the probability of errors.