Department of Neurosurgery and Brain Metastasis Center, Memorial Sloan Kettering Cancer Center, New York, NY.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
JCO Oncol Pract. 2022 Nov;18(11):e1732-e1738. doi: 10.1200/OP.22.00258. Epub 2022 Aug 29.
Timely surgical cavity stereotactic radiosurgery (SRS) is an important adjuvant to brain metastasis resection, with earlier treatment associated with less frequent recurrence. The logistical complexity of treatment organization, however, has resulted in suboptimal start times postsurgically. We implemented a process improvement approach to reduce the time from surgery to adjuvant irradiation of resected brain metastases.
A multidisciplinary working group used process mapping to identify opportunities to reduce visits and shorten treatment times. The care delivery process was modified to streamline perioperative SRS preparation with (1) early patient identification, (2) preoperative intrateam communication, and (3) consolidation of required steps. Plan-Do-Study-Act cycles were used for process improvement. The surgery-to-SRS initiation time interval was the primary outcome. Secondary outcomes included the number of associated patient encounters.
After implementation, the median (interquartile range) interval from surgery to SRS was reduced 48% from 27 (21-34) to 14 days (13-17; < .001). The rate of surgical cavity SRS within 30 days increased from 64% (n = 63 of 98) to 97% (n = 60 of 62; < .001). The median (interquartile range) number of CNS-associated encounters between resection and SRS decreased from 5 (4-6) to 4 (3-5; < .001). The proportion of patients who had > 1 magnetic resonance imaging/computed tomography between surgery and SRS decreased from 45% (44 of 98) to 13% (8 of 62; < .001). The time from surgery to systemic therapy resumption/initiation among patients treated within 90 days postoperatively decreased from 35 (24-48) to 32 days (23-40; = .074). There were no wound complications in either group.
Adjuvant SRS latency and treatment-associated encounters were significantly reduced after care-coordination implementation. This approach reduces patient and health care system burden and can be applied to other scenarios where early postoperative SRS administration is critical.
及时进行手术腔立体定向放射外科（SRS）是脑转移瘤切除的重要辅助手段，治疗时间越早，复发频率越低。然而，由于治疗组织的后勤复杂性，导致手术后开始治疗的时间不理想。我们采用了一种改进流程的方法，以减少脑转移瘤切除术后辅助放疗的时间。
一个多学科工作组使用流程映射来确定减少就诊次数和缩短治疗时间的机会。通过（1）早期患者识别、（2）术前团队内沟通和（3）所需步骤的整合，对护理提供流程进行了修改，以简化围手术期 SRS 准备工作。使用计划-执行-研究-行动循环进行流程改进。手术至 SRS 启动时间间隔是主要结局。次要结局包括相关患者就诊次数。
实施后，手术至 SRS 的中位数（四分位距）间隔从 27 天（21-34 天）缩短至 14 天（13-17 天；<0.001）。30 天内进行手术腔 SRS 的比例从 64%（98 例中的 63 例）增加到 97%（62 例中的 60 例；<0.001）。切除和 SRS 之间的中枢神经系统相关就诊次数中位数（四分位距）从 5 次（4-6 次）减少至 4 次（3-5 次；<0.001）。手术和 SRS 之间进行>1 次磁共振成像/计算机断层扫描的患者比例从 45%（98 例中的 44 例）降至 13%（62 例中的 8 例；<0.001）。在 90 天内接受治疗的患者中，从手术到恢复/开始全身治疗的时间从 35 天（24-48 天）减少至 32 天（23-40 天；=0.074）。两组均无伤口并发症。
实施护理协调后，辅助 SRS 潜伏期和治疗相关就诊次数显著减少。这种方法减轻了患者和医疗保健系统的负担，可应用于其他需要尽早进行术后 SRS 治疗的情况。
