Optimising access and provision of interventional radiology service to patients by utilising a new referral system.

OBJECTIVE: Implementing a streamlined interventional radiology (IR) service in the UK has been a challenge. This study aims to review a set of changes introduced in IR at a tertiary centre, including a new referral process and the designation of IR clinical nurse specialists. METHODS: A new process of referring patients to IR using a single generic referral pathway was implemented, replacing an order dropdown-based system. A qualitative survey was designed and distributed as a single-use web link in order to assess the satisfaction and impact of this new process. Responses were based on Likert scale and pertained to perceived qualities of the new referral process. Data analysis was performed to identify specialty and grade-specific trends and possible differences amongst groups. RESULTS: Findings from 98 respondents revealed a strong overall satisfaction with the new referral method and support for its continuation. Subgroup analysis by specialty, concluded medical specialties rated the new referral system more favourably than surgical specialties across all aspects: time efficiency, ease of use, periprocedural support and overall user experience. The new system also increased departmental productivity with an increase in the number of patients treated by 11.2%. CONCLUSION: Micropolicy changes within individual IR departments such as the replacement of a request-based referral system to one which puts IR in control of vetting and patient flow is one of many changes that reinforce the transformational phase of this specialty. ADVANCES IN KNOWLEDGE: Micropolicy changes within IR departments are key in the progression and widespread recognition of the specialty.

Overall Impact of the COVID-19 Pandemic on Interventional Radiology Services: A Canadian Perspective.

PURPOSE: The aim of this national survey was to assess the overall impact of the coronavirus disease 2019 (COVID-19) pandemic on the provision of interventional radiology (IR) services in Canada. METHODS: An anonymous electronic survey was distributed via national and regional radiology societies, exploring (1) center information and staffing, (2) acute and on-call IR services, (3) elective IR services, (4) IR clinics, (5) multidisciplinary rounds, (6) IR training, (7) personal protection equipment (PPE), and departmental logistics. RESULTS: Individual responses were received from 142 interventional radiologists across Canada (estimated 70% response rate). Nearly half of the participants (49.3%) reported an overall decrease in demand for acute IR services; on-call services were maintained at centers that routinely provide these services (99%). The majority of respondents (73.2%) were performing inpatient IR procedures at the bedside where possible. Most participants (88%) reported an overall decrease in elective IR services. Interventional radiology clinics and multidisciplinary rounds were predominately transitioned to virtual platforms. The vast majority of participants (93.7%) reported their center had disseminated an IR specific PPE policy; 73% reported a decrease in case volume for trainees by at least 25% and a proportion of trainees will either have a delay in starting their careers as IR attendings (24%) or fellowship training (35%). CONCLUSION: The COVID-19 pandemic has had a profound impact on IR services in Canada, particularly for elective cases. Many centers have utilized virtual platforms to provide multidisciplinary meetings, IR clinics, and training. Guidelines should be followed to ensure patient and staff safety while resuming IR services.

The COVID-19 pandemic and its repercussions in our interventional radiology unit. / La pandemia COVID-19 y su repercusión en la unidad de radiología intervencionista: nuestra experiencia.

This paper aims to describe our experience in an interventional radiology unit in a hospital in Spain that was severely affected by the COVID-19 pandemic. To this end, we did a prospective observational study of 20 consecutive patients with COVID-19 who underwent 21 interventional radiology procedures between March 13, 2020 and May 11, 2020. We describe the measures taken to reorganize the work and protective measures, as well as the repercussions of the situation on our unit's overall activity and activity in different phases. The COVID-19 pandemic has represented a challenge in our daily work, but learning from our own experience and the recommendations of the Spanish radiological societies (SERVEI and SERAM) has enabled us to adapt successfully. Our activity dropped only 22% compared to the same period in 2019.

Future scenarios and opportunities for interventional radiology in the post COVID-19 era.

Pandemic outbreak has led health systems worldwide into a rapid reorganization in response to coronavirus infections, forcing interventional radiology units to adapt. Interventional procedures have evolved in number, type and setting and have arguably been optimized as a direct consequence of this pandemic; a result that will undoubtedly lead to radical change within the specialty. This paper explores the future of interventional radiology from various perspectives, and forecasts the new opportunities that will be presented, from the adaptation of the interventional radiology staff and angiography suite, to the immunological environment, and through to digital medical education. We analyze the economic impact and the future relationship we can expect with the rest of the medical industry.

Over 12 Years Single Institutional Experience Performing Percutaneous Hepatic Perfusion for Unresectable Liver Metastases.

Patients with unresectable hepatic metastases, from uveal or ocular melanoma, are challenging to treat with an overall poor prognosis. Although over the past decade significant advances in systemic therapies have been made, metastatic disease to the liver, especially from uveal melanoma, continues to be a poor prognosis. Percutaneous hepatic perfusion (PHP) is a safe, viable treatment option for these patients. PHP utilizes high dose chemotherapy delivered directly to the liver while minimizing systemic exposure and can be repeated up to 6 times. Isolation of the hepatic vasculature with a double-balloon catheter allows for high concentration cytotoxic therapy to be administered with minimal systemic adverse effects. A detailed description of the multidisciplinary treatment protocol used at an institution with over 12 years of experience is discussed and recommendations are given. A dedicated team of a surgical or medical oncology, interventional radiology, anesthesiology and a perfusionist allows PHP to be repeatedly performed as a safe treatment strategy for unresectable hepatic metastases.

Developing a Spinal CSF Leak Program in a Multihospital Network.

OBJECTIVE: Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare and challenging to diagnose and treat. Patients may present to a variety of physicians, and many patients are often referred to a specialized center with a dedicated spinal CSF leak program and expertise in this condition. To our knowledge, there are no reported publications on how to create such a program. CONCLUSION: In this article, we describe the specific steps we took to develop a spinal CSF leak program, which we have implemented over a multihospital network.

Developing an intraoperative 3T MRI-guided brachytherapy program within a diagnostic imaging suite: Methods, process workflow, and value-based analysis.

PURPOSE: We integrated a brachytherapy procedural workflow within an existing diagnostic 3.0-T (3T) MRI suite. This setup facilitates intraoperative MRI guidance for optimal applicator positioning, particularly for interstitial needle placements in gynecologic cases with extensive parametrial involvement. METHODS AND MATERIALS: Here we summarize the multidisciplinary collaboration, equipment, and supplies necessary to implement an intraoperative MRI-guided brachytherapy program; outline the operational workflow via process maps; and address safety precautions. We evaluate internal resource utilization associated with this progressive approach via time-driven activity-based costing methodology, comparing institutional costs to that of a traditional workflow (within a CT suite, followed by separate postprocedure MRI) over a single brachytherapy procedural episode. RESULTS: Resource utilization was only 15% higher for the intraoperative MRI-based workflow, attributable to use of the MRI suite and increased radiologist effort. Personnel expenses were the greatest cost drivers for either workflow, accounting for 76-77% of total resource utilization. However, use of the MRI suite allows for potential cost-shifting opportunities from other resources, such as CT, during the procedural episode. Improvements in process speed can also decrease costs: for each 10% decrease in case duration from baseline procedure time, total costs could decrease by roughly 8%. CONCLUSIONS: This analysis supports the feasibility of an intraoperative MRI-guided brachytherapy program within a diagnostic MRI suite and defines many of the resources required for this procedural workflow. Longer followup will define the full utility of this approach in optimizing the therapeutic ratio for gynecologic cancers, which may translate into lower costs and higher value with time, over a full cycle of care.

La pandemia COVID-19 y su repercusión en la unidad de radiología intervencionista: nuestra experiencia / The COVID-19 pandemic and its repercussions in our interventional radiology unit

El objetivo del presente trabajo es mostrar la experiencia en una unidad de radiología intervencionista de un hospital de nuestro país muy afectado por la pandemia COVID-19. Para ello se ha realizado un estudio observacional prospectivo de una serie de casos consecutivos (n=20) de pacientes COVID-19, sometidos a 21 procedimientos intervencionistas, durante el periodo de 2 meses de estudio (13 marzo -11 mayo de 2020). Se exponen las medidas de reorganización del trabajo, medidas de protección; así como la repercusión de la situación en la actividad de la unidad total y por fases. La pandemia COVID-19ha supuesto un reto para el trabajo diario en nuestra unidad, pero siguiendo nuestra propia experiencia y las recomendaciones de SERVEI y SERAM, nos hemos adaptado a la situación de forma exitosa. Se ha observado una disminución de la actividad de tan sólo un 22% sobre el mismo periodo del año 2019

This paper aims to describe our experience in an interventional radiology unit in a hospital in Spain that was severely affected by the COVID-19 pandemic. To this end, we did a prospective observational study of 20 consecutive patients with COVID-19 who underwent 21 interventional radiology procedures between March 13, 2020 and May 11, 2020. We describe the measures taken to reorganize the work and protective measures, as well as the repercussions of the situation on our unit's overall activity and activity in different phases. The COVID-19 pandemic has represented a challenge in our daily work, but learning from our own experience and the recommendations of the Spanish radiological societies (SERVEI and SERAM) has enabled us to adapt successfully. Our activity dropped only 22% compared to the same period in 2019

Access to Comprehensive Services for Advanced Liver Disease in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) provides care to the one of the largest cohorts of patients with advanced liver disease (ALD) in the USA. AIMS: We performed a national survey to assess system-wide strengths and barriers to care for Veterans with ALD in this national integrated healthcare setting. METHODS: A 52-item survey was developed to assess access and barriers to care in Veterans with ALD. The survey was distributed to all VHA medical centers in 2015. Results were analyzed using descriptive statistics. RESULTS: One hundred and fifty-three sites responded to this survey. Multidisciplinary services were available on-site at > 80% of sites. Ninety-five percent of sites had mental health and addictions treatment available, with 14% co-locating these services within the liver clinic. Few sites (< 25%) provided pharmacologic treatment for alcohol use disorder in primary care or hepatology settings. Seventy-two percent of sites reported at least one barrier to liver-related care. Of the sites reporting at least one barrier, 53% reported barriers to liver transplant referral, citing complex processes and lack of staff/resources to coordinate referrals. Palliative care was widely available, but 61% of sites reported referring < 25% of their patients with ALD for palliative services. CONCLUSION: Multidisciplinary services for Veterans with ALD are widely available at VHA sites, though barriers to optimal care remain. Opportunities for improvement include the expansion of providers with hepatology expertise, integrating pharmacotherapy for alcohol use disorder into hepatology and primary care, streamlining the transplant referral process, and expanding palliative care referrals for patients with ALD.

Establishing IR in Emerging Countries-A Skill Development Initiative.

Integrating interventional radiology (IR) into clinical practice faces challenges in emerging countries in Asia and Africa. Overcoming them requires innovative solutions customized to local needs. After an in-depth gap analysis of these challenges, we began an organized skill development initiative in late 2015 offering radiologists and their supporting staff fully paid scholarships for IR training. Its concept, structure, and progress are reported here. This initiative covered 8 countries, IR specialists (n = 51), senior residents (n = 24), and 15 educational events (training institute [n = 3]; participating countries [n = 12]). This initiative is intended to develop a global network of trained personnel who can support IR programs in challenging locations of emerging countries.

Aviation and Procedural Medicine.

Aviation and medicine are two complex fields involving many interdependent steps where problems can occur. When they inevitably do the outcome can be catastrophic, leading to injury or even loss of life. While both professions have made great strides to reduce error and improve safety, we would suggest medicine can still learn much from the approach aviation has developed. We will show how pilots spend a significant amount of time on planning and early recognition of impending challenges, utilize the concept of crew resource management routinely, and stay much focused during each specific mission. More importantly, they are very open and committed to discussing every event or near event to improve the system, and are supported in this by their superiors without fear of punishment or retribution. By adopting many of these principles, medicine can develop a true culture of safety such as aviation has done, leading to a remarkable improvement in their safety record.

Positive Impact of an Aortic Center Designation.

BACKGROUND: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center. METHODS: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014. Primary outcomes included the number of all aortic related procedures, transfer acceptance rate, transfer time, and proportion of elective/emergent referrals. RESULTS: The Aortic Center included 5 vascular surgeons, 2 cardiac surgeons, and 2 interventional radiologists. Workflow processes were implemented to streamline patient transfers as well as physician and operating room notification. Total aortic volume increased significantly from 162 to 261 patients. This reflected an overall 59% (P = 0.0167) increase in all aorta-related procedures. We had a 65% overall increase in transfer requests with 156% increase in acceptance of referrals and 136% drop in transfer denials (P < 0.0001). Emergent abdominal aortic cases accounted for 17% (n = 45) of our total aortic volume in 2015. The average transfer time from request to arrival decreased from 515 to 352 min, although this change was not statistically significant. We did see a significant increase in the use of air-transfers for aortic patients (P = 0.0041). Factorial analysis showed that time for transfer was affected only by air-transfer use, regardless of the year the patient was transferred. Transfer volume and volume of aortic related procedures remained stable in 2016. CONCLUSIONS: Designation as a comprehensive Aortic Center with implementation of strategic workflow systems and a culture of "no refusal of transfers" resulted in a significant increase in aortic volume for both emergent and elective aortic cases. Case volumes increased for all specialties involved in the center. Improvements in transfer center and emergency medical services communication demonstrated a trend toward more efficient transfer times. These increases and improvements were sustainable for 2 years after this designation.