Thinking Outside the Brachytherapy Suite: A Novel Radiation Therapist-led Approach for Gold Seed Insertions

Purpose/Aim

There are 400 patients treated with prostate stereotactic body radiation therapy (SBRT) at our institution annually. To facilitate image guidance, patients require insertion of three gold seeds (GS) prior to simulation, which is a stress on departmental resources given patient volumes. GS are implanted by a Radiation Oncologist in our brachytherapy (BT) suite under local anaesthesia, using trans-rectal ultrasound guidance through the perineum, during limited non-anaesthesia time. Nursing (RN) assumes responsibility for patient teaching, vital signs, and procedural monitoring, while Radiation Therapists (RTTs) are responsible for sterile field and ultrasound preparation, equipment troubleshooting, and patient positioning. Here, we describe a novel and lean RTT-led workflow implemented at our centre for GS insertions for prostate SBRT.

Methods/Process

Opportunities for improvement in the existing GS workflow, identified through a mapping exercise, included procedure location, patient education, and task-sharing amongst the interprofessional team. Given limited non-anaesthesia time within our BT suite, our sporadically used orthovoltage bunker was selected as an alternate location and equipped for procedures, with a room layout designed by RTTs to facilitate GS insertion. Updated patient education handouts, encompassing pre- and post-procedure instructions, were developed by RTTs and RNs in conjunction with patient and family education. New patient teaching guidelines were formalized to allow RTTs to assume responsibility. A protocol for RTT-led pre-procedural time-outs was implemented, adapted with RN input from surgical time-outs used for general anaesthesia cases. RTTs were trained in procedural monitoring, covering pre-procedural concerns such as anti-coagulation, indications for vital signs monitoring, and recognizing signs and symptoms of local anaesthetic systemic toxicity, supported by a process map for managing adverse events including guidelines for re-engaging RN support. Surgical documentation was modified in collaboration with RNs for use by RTTs from pre-procedural teaching to patient discharge. RTT-led GS insertions were implemented iteratively, with regular evaluation by the interprofessional team to identify any potential gaps in knowledge and sequential adjustment of the workflow, ensuring continuous quality of patient care.

Results or Benefits/Challenges

GS insertions in our orthovoltage bunker can be completed in parallel to procedures in our BT suite, representing significant resource optimization and potential for expansion of our BT program. Our novel workflow represents significant role expansion for RTTs, who now provide continuous care to patients throughout the GS insertion process. Organization of the orthovoltage bunker for use as a procedure room required numerous iterations to achieve optimal functionality. Perceived scope creep from nursing was mitigated through interprofessional collaboration throughout the development, evaluation and implementation of the new GS workflow. A process for new patient teaching via telephone was developed to decrease booking times and align with previous RN practice. Increased number of RTTs staffed to BT and adjustments to daily staff scheduling were required to accommodate parallel procedure rooms.

Conclusions/Impact

Starting in October 2023, 386 patients have had gold seed insertions completed with our new RTT-led workflow. We continue to evaluate and improve this process to provide the most optimal care to our patients.