Keywords
Radioiodine Therapy - No-Care - Student assistants - nursing staff shortage
Introduction
Nursing staff in nuclear medicine represents an important pillar for radionuclide
therapy. The situation in Germany is characterized by strict radiation protection
laws, requiring in-patient treatment for most systemically applied therapies in order
to handle radioactive excretions and protect surrounding persons from avoidable radiation
exposure. The duration of the hospital stay varies from 2 days (most of excess radioactivity
has been renally excreted by then) to approx. 3 weeks (until dosage rate limits for
safe dismissal are reached). The majority of patients are released from the nuclear
medicine ward in less than 4 days of hospitalization. [Table 1] summarizes the most frequent indications/diseases. It has to be emphasized that
there are long-term in-patient treatments, especially in cases of large goiters and
high amounts of therapeutic activity (>1.2 GBq I-131) or metastasized thyroid cancer
and very high amounts of therapeutic activity (>5 GBq I-131).
Table 1 Numbers of nuclear medicine in-patient treatment cases in Germany in 2024, according
to [1]. * Considering various origins for neuroendocrine tumors, OPS (Operationen- und
Prozedurenschlüssel) was chosen instead of DRG in order to retrieve correct data.
DRG: Diagnosis related group, rhTSH = recombinant human thyroidea-stimulating hormone,
HCC = hepatocellular carcinoma, CCC= cholangiocellular carcinoma, mCRC = metastasized
colorectal carcinoma, TARE = transarterial radioembolization, SD = standard deviation.
|
DRG
|
Disease
|
Radiopharmaceutical
|
Cases 2024
|
Duration (days; mean ± SD)
|
|
K15E
|
Benign thyroid disease
|
<1.2 GBq I-131
|
12929
|
3.1±1.7
|
|
K15D
|
Benign thyroid disease
|
1.2–5.0 GBq I-131
|
1526
|
6.0±3.4
|
|
|
sum
|
14455
|
|
|
M10B
|
Prostate Cancer
|
7.4 GBq Lu-177-PSMA
|
8266
|
2.4±0.9
|
|
K15A
|
Thyroid cancer
|
>5.0 GBq I-131
|
4265
|
2.9±1.1
|
|
Z64A, -B
|
Thyroid cancer, diagnostic ± rhTSH
|
0.4 GBq I-131
|
3529
|
2.4±0.5
|
|
8–530.61,-2*
|
Neuroendocrine Tumors
|
7.4 GBq Lu-177-DOTATATE, -TOC
|
3435
|
2.6±2.5
|
|
K15C
|
Thyroid cancer
|
1.2–5.0 GBq I-131
|
2425
|
3.2±1.8
|
|
H29Z
|
HCC, CCC, mCRC
|
0.5–5 GBq Y-90 Particles, TARE
|
743
|
2.8±2.2
|
|
|
sum
|
22663
|
|
Two diametric aspects have shaped the landscape of nuclear medicine treatments over
the past decade:
-
Nowadays, patients treated on nuclear medicine wards are older, have more comorbidities
and present in a worse general shape than 10 years ago. This is attributable to the
rise and increasing use of tumor-specific radioligand therapies, especially Lu-177-PSMA
(including Pluvicto and patient-individual in-house produced Lu-177-PSMA) and Lu-177-labelled
somatostatin analogs (including Lutathera and patient-individual in-house produced
Lu-177-DOTATOC/-TATE) as well as emerging radioligand therapies (e.g. Lu-177-FAPI)
that have been used as last line in heavily pretreated cancer patients [2]. Regarding commercially available radiopharmaceuticals, a trend towards less heavily
pretreated cancer patients has been observed recently. These factors contribute to
a high need in professional nursing care including specialized oncology nursing staff
with adequate knowledge of patient needs in late-stage cancer as well as psychological
and physical robustness.
-
Nursing staff has become a scarce resource. As of today, there is a shortage of nurses
in hospitals, out-patient care and nursing homes [3]. The demand of additional nurses in hospitals is estimated at 100000 until 2049
[4].
Despite of the increasing morbidity of patients on nuclear medicine wards, it is important
to consider that approx. one third of the patients on the nuclear medicine ward consist
of rather healthy patients requiring radioiodine therapy of goiter or hyperfunctioning
thyroid nodules [1] ([Table 1]). Typically, these patients are not much affected by the thyroid disease and neither
symptoms of hyperthyroidism nor acute side effects of radioiodine therapy require
a hospital admission for medical reasons (except rare cases of thyrotoxicosis, severe
ophthalmopathy or airway compression) [5]. This group of patients is on the nuclear medicine ward solely for radiation protection
reasons and does not require specific nursing staff. Considering the shortage of nursing
staff, it seems irrational to allocate highly trained nursing staff to a nuclear medicine
ward hosting rather healthy patients.
Without doubt, it is not constructive to demand a decrease of nursing staff in view
of the increasingly challenging group of cancer patients treated in nuclear medicine.
But if a spatial or temporal separation of thyroid patients (without requirement of
full care; no-care) and cancer patients (full-care) is feasible ([Fig. 1]), the use of less qualified personnel can be considered for a no-care nuclear medicine
ward.
Fig. 1 Two concepts of patient separation. a) spatial separation requiring two separated, fully functioning nuclear medicine wards
which can be used at the same time. b) temporal separation requiring only one nuclear medicine ward. Patients are scheduled
according to their eligibility for a “full-care” or “no-care” week.
During the past two years we developed a concept of spatial separation for a nuclear
medicine ward in a university hospital, successfully dividing patients into two groups
(suitable/not suitable for a no-care-ward) and training medical students (student
assistants) to carry out tasks to support the patients during the in-patient stay.
Here, we report on a) the implementation and training process, b) patient and student
satisfaction as assessed by two separate surveys. Lastly, we discuss the impact and
strengths as well as limitations of this concept.
Materials/Methods
Ethics
All participants of the questionnaire agreed to the use of their data for scientific
purposes and provided written informed consent. All investigations were conducted
in accordance with the declaration of Helsinki as revised in 2013. The ethical authorization
was given by the Ethics Commission of the University Clinic Jena. Date of permission
was January 12, 2024, with the registration number 2024-3207.
Nuclear medicine wards
The concept of spatial separation was implemented in 2024 in a university hospital
in Germany. Due to new construction of a substantial part of the entire university
hospital, a new nuclear medicine ward hosting 11 patient beds was put into operation
in 2017. The formerly used nuclear medicine ward was refurbished in 2010 and is equipped
with 7 patient rooms (3× two beds, 4× one bed) and a fully functioning decay installation
as required per national legislation. It served as a back-up ward from 2017 to 2024
in times of outage and maintenance of the new nuclear medicine ward, thus technical
availability was sustained. The former nuclear medicine ward was chosen for implementation
of the no-care-concept (no-care-ward) while operation of the newer nuclear medicine
ward (full-care-ward) was maintained at the same time.
Student assistants
Student assistants were casted for work on the nuclear medicine ward. An invitation
email was sent to all medical students regardless of the year of medical school and
34 students replied. Of these, 27 students received training of minimum two 8-hours
shifts on the new nuclear medicine ward, familiarizing the students with commonly
treated diseases, workflows, documentation processes and radiation protection. Latter
was intensified by a qualified instruction by medicine physicist experts.
Per shift, two student assistants were assigned according to previously stated working
time preferences. Thus, each day, six students worked on the nuclear medicine ward
(early shift 06.00 am – 2.15 pm, late shift 1.45 pm – 10.00 pm, night shift 9.30 pm
– 06.15 am), ensuring 24/7 on-site support of the patients. The number of two students
per shift was chosen in order to have a backup in case of illness and to reduce errors
and overburdening due to one person only on site. Occupational dosimetry was performed
according to national legislation using standard dosimeters (LPS-OSL-GD 01 Hp,10 DE-17-M-PTB-0001;
Physikalisch Technische Bundesanstalt, Braunschweig, Germany; lower detection limit:
0.1 mSv) which were analyzed retrospectively.
Patients
Patient groups eligible for the no-care-ward were defined according to specific inclusion
and exclusion criteria ([Table 2]) during a mandatory pretherapeutic radioiodine uptake test which took place 1–10
weeks before in-patient treatment. The final decision was made by a board-certified
nuclear medicine specialist. In short, only self-dependent patients requiring radioiodine
therapy (RIT) for benign thyroid disease were considered for the no-care-concept.
No limits were defined regarding the amount of administered activity or planned duration
of the in-patient stay. Upon admission, each patient was seen by a doctor and when
giving informed consent regarding radioiodine therapy, was concomitantly instructed
regarding their stay on the no-care-ward.
Table 2 Inclusion and exclusion criteria for eligibility of patients with benign thyroid diseases
to be treated on a “no-care” nuclear medicine ward. RIT = Radioiodine therapy, NET
= neuroendocrine tumor, TARE = transarterial radioembolization, TSH = thyroidea stimulating
hormone, ULN = upper limit normal.
|
Inclusion criteria
|
Exclusion criteria
|
|
Indication
|
RIT for
-
Thyroid autonomy
-
Graves disease
-
Goiter
|
RIT for thyroid cancer
Radioligand therapy for Prostate cancer
Radioreceptor therapy for NET
TARE for liver tumor
|
|
Urgency
|
Not urgent (RIT in < 3 months acceptable)
|
Urgent (RIT in < 1 month necessary)
|
|
Lab values
|
TSH of any value
fT3, fT4 < 1.5 ULN
GFR > 50 ml/min
Hemoglobin > 7.0 mmol/l
|
fT3, fT4 > 1.5 ULN
GFR < 50 ml/min
Hemoglobin < 7.0 mmol/l
|
|
Self-assessment, general state
|
Good, very good
|
Moderate, poor
|
|
Concomitant disease
|
Allowed:
Arterial hypertension
Diabetes mellitus (non-insulin dependent)
Hypercholesterinemia
Smoking habit
|
Asthma (requiring inhalative therapy)
History of Epilepsy
Diabetes mellitus (insulin dependent)
Psychiatric disorders
Incontinency
Dementia
Alcohol addiction
History of coronary heart disease
Surgery within the last 6 months
Increased risk of falling
|
|
Medication
|
Self-dependent intake of regular oral medication, e.g.
Antihypertensives, statins
|
Inability to prepare and self-administer oral medication
Any intravenous, subcutaneous or intramuscular medication
Insulin
Asthma spray
Anticoagulants
|
|
Doctor’s judgement
|
Eligible
|
Not eligible
|
Questionnaires
Patient questionnaires used to assess general patient satisfaction were distributed
to the patients on the day before dismissal from the nuclear medicine ward. The questionnaire
was identical to the one used in the entire university hospital and consisted of 9
items assessing different topics of satisfaction (structured procedures, medical treatment,
nursing, information, nutrition, cleanliness, facilities/equipment) and recommendation
(likeliness of return for future treatments, likeliness of recommendation) using a
4-point Likert scale (always, mostly, rarely, never). In the event of dissatisfaction,
patients were invited to select multiple subitems regarding desired improvements.
The student questionnaire was developed to assess experience and preparedness, support,
time for extra activities, stress and workload as well as benefit for personal development
using appropriate Likert scales. 12 items were included in the survey and additional
open questions were integrated to give individual feedback. The questionnaire was
answered after the first two (of six) opening phases.
Results
The nuclear medicine ward was opened six times between April 2024 and June 2025 and
the duration was three times 14 days, two times 10 days and one time 20 days (82 days
total). Regarding the capacity of 10 beds, this is equivalent to 820 bed*days. During
this period, 101 patients were treated for benign thyroid disease and 590 bed*days
were occupied (72% operating grade). In 17 patients, >1.2 GBq I-131 was administered
(DRG: K15D) and in 84 patients <1.2 GBq I-131 was administered (DRG K15E). Patients
were released from the nuclear medicine ward when the dosage rate fell below 3.5 µSv/h
in 2 meter distance, according to national legislation. In-patient stay was 9.3±3.6
days (median 10 days; range 3–14 days) for K15D and 5.1±3.9 days (median 3 days; range
2–16 days) for K15E, respectively. In total, 68547 DRG relative units (DRG Relativgewichte)
were achieved which is equivalent to approx. 295000 Euros revenue. Regarding personnel
costs, student assistants were paid minimum wage (15 Euros/hour) which resulted in
approx. 59000 Euros for 82 days, considering the presence of 6 students each day.
Patients were 62.1± 10.4 years old (median 63 years; range 27–84 years) which is significantly
younger than the patients treated on the full-care nuclear medicine ward during the
time between April 2024 and June 2025 (n=805 patients, 65.5±13.4 years (median 67
years; range 6–93 years); p = 0.0005).
From April 2024 to June 2025, 340 patients underwent a pretherapeutic radioiodine
uptake test. In 21 patients, RIT was not recommended (either no treatment necessary
or surgery preferred) and of the remaining 319 patients, 172 (53.9%) were found to
meet inclusion criteria for RIT on the no-care-ward. 61 patients received RIT on the
full-care-ward due to efficiency in operating grade.
The patient questionnaire revealed excellent satisfaction with very high positive
response rates and only a few negative answers ([Fig. 2]). The patients felt well informed and emphasized their strongly positive view on
nursing care by the students. Negative ratings were given for meals, cleanliness and
general equipment.
Fig. 2 Results of patient questionnaire for nine different items. Positive evaluation is
presented as blue bars, negative evaluation as red bars.
Initially, 34 students replied to the email and 27 decided to start training on the
full-care nuclear medicine ward. Students’ age was 21.8 ±1.6 years (median 22; range
19–25) and comprised 22 female, 5 male and 0 diverse. 14/27 students had already been
working as student assistants on different wards in other departments of the university
clinic. [Fig. 3] shows the students’ grade in medical school (a), how many training shifts were taken
(b) and how many shifts they worked before answering the questionnaire (c).
Fig. 3 Student assistants’ grade in medical school (a), training shifts (b) shifts before answering the questionnaire (c).
Occupational dosimetry revealed minimally detectable values of 0.1 mSv/one month in
2/27 students.
Student questionnaire results are shown in [Fig. 4]. 24/27 students took part in the questionnaire and 22/27 (81%) completed all questions.
The overall judgement was positive, and students felt well prepared. Stress was not
perceived. The majority of students stated a positive effect on overall medical knowledge
as well as an improvement in their understanding of workflows in a hospital. One student
admitted that the work on the nuclear medicine ward convinced him/her to consider
nuclear medicine as a specialization after medical school.
Fig. 4 Results of student assistant questionnaire for twelve different items. Positive evaluation
is presented as blue bars, negative evaluation as red bars.
Discussion
Therapeutic nuclear medicine has changed over the past decade [6]. 15 years ago, the majority of patients on a nuclear medicine ward underwent radioiodine
therapy for benign thyroid diseases; a therapy that is well-tolerated and not associated
with severe acute side-effects. The main reason for these patients for an in-patient
stay is radiation protection laws, not medical reasons in the narrow sense. Today,
more patients are being treated for cancer on a nuclear medicine ward, often after
having received multiple systemic therapies, thus being heavily pretreated and influenced
by this pretreatment and/or cancer (and its metastases) itself [2]. This leads to an increasing demand for specialized nuclear medicine nursing staff
capable of adequately taking care of the patients [7]
[8]. Shortage of specialized nursing staff represents a major challenge for the German
healthcare system in general and of course, this also applies for nuclear medicine
nursing staff [9].
However, albeit clear increase of cancer patients on nuclear medicine wards [2] and decreasing prevalence of thyroid diseases [10]
[11], including conditions in need of therapy, it has to be remembered that approx. one
third of patients on nuclear medicine wards are patients receiving a radioiodine therapy
for benign thyroid disease. This is also a trend observed in other countries, e.g.
the United Kingdom [12].
The current report shows that the concept of a no-care-ward is feasible in selected
patients. Considering the implementation of this concept into clinical workflow, this
group of patients represents an almost ideal clientele involving the following advantages:
All types of RIT are planned and there are no emergency admissions to the hospital.
All patients require a pretherapeutic radioiodine uptake test which is usually performed
in an out-patient setting. Thus, it is possible to screen the patients according to
their eligibility.
Student assistants
Student assistants consistently reported positive experiences during their work on
the no-care-ward. This is on one hand attributable to low requirements/stress and
high gratification (positive feedback, salary) and on the other hand the benefit of
gathering experience before finishing medical school. The detailed documentation a
nurse has to do, close communication with patients, self-responsible handling of situations
(e.g. contaminated food tray, missing supplies, patients’ worries during therapy)
and patient-centered structured work are competences that are not primarily taught
in medical school. The currently proposed concept is similar to training wards which
have been implemented in medical schools in Germany over the past decade and established
in Scandinavian countries for more than 20 years [13]
[14]. Numerous publications describe the positive learning environment and effectiveness
as well as interdisciplinary collaboration and communication [15]. Interdisciplinary training wards hosting medical students as well as nursing apprentices
and other professions have been found to greatly enhance interprofessional comprehension
and insight [16]. Most of the concepts rely on close supervision, briefing and de-briefing meetings
in order to analyze workflows and situations [16]. Although every student on the no-care-ward was encouraged to ask questions in case
of uncertainty or ambiguity about certain situations and doctors, experienced nurses
as well as medicine physicist experts provided close support. However, a structured
supervision was not implemented which represents a limitation.
Patients
Patient safety was ensured at all times and patient questionnaires revealed almost
exclusively positive evaluation. No critical incident was reported. This met the expectations
the authors had before implementing the no-care-concept and reflects the nature of
RIT in patients with benign thyroid diseases. However, the very positive result is
likely to be biased, as patients were aware of the recent implementation of the no-care-concept
and the conversation between doctor and patient was more extensive than a regular
pre-treatment consultation. Thus, it was ensured that patients had a positive and
benevolent attitude before RIT was started [17]. Additionally, students showed high motivation, knowing that the patients and the
clinic staff had high expectations and thus, they put much effort into doing an optimal
job. The positive influence of patient-centered care instead of nursing-defined care
in hospitals has been well examined [18]. Furthermore, a recent study by Hellinger et al. reported on the safety and patient
satisfaction of an interprofessional training ward in visceral surgery, describing
the training ward as a safe concept for patients and that satisfaction levels are
even higher than on a regular ward [19]. This is in line with our findings and additionally, it has to be emphasized that
visceral surgery possesses a much higher potential for adverse events compared to
radioiodine therapy.
Financial aspects
In Germany, reimbursement of hospital costs is based on DRG-system which was introduced
in 2000 and modified in 2020 regarding outsourcing of nursing reimbursement (aG-DRG).
The goal of this modification was to avoid unjustified overpayment of nursing costs,
and it was assumed that separation of payment for medical treatment and nursing effort
would lead to a more accurate cost allocation and reimbursement reflecting actual
effort (particularly aiming at adequate coverage of actual nursing costs). It was
determined that these costs would henceforth be financed by a nursing budget (negotiated
by each hospital with the respective providers). aG-DRG-reimbursement of approx. 295000
Euro covers the costs for the student assistants and leaves approx. 236000 Euro for
further costs, i.e. radioiodine capsules, maintenance, infrastructure, energy, food,
doctors’ salary. Comparing the budget spent on student assistants with regular nursing
staff is difficult and needs closer differentiation. To adequately care for the selected
patient group, it is not necessary that two experienced nurses are present on a nuclear
medicine ward 24/7. It is common practice to provide two nurses during early shift
and one nurse during late and night shift, respectively. Given a median salary of
nurses of 4108 Euros/month [3], the comparable staff budget for experienced nurses calculates to 62000 Euro for
82 days and is therefore slightly higher than the budget spent on students. Considering
cost-effectiveness of similar concepts, it has been reported that interdisciplinary
training wards in Germany during COVID-19 pandemia contributed to the health system
in a cost-effective way [20]. Despite a trend towards minor staff expenditure, it must be kept in mind that this
is not the main reason for establishing a concept like this. The primary motivation
is the increasing shortage of experienced and professional nurses and assistance staff.
Limitations
This report has several limitations lowering the overall impact. First, it is a single
center experience, that has been developed over a longer period of time and that has
been adjusted. The transferability to other nuclear medicine wards might be limited
due to a different infrastructure (this concept was only possible because of a second,
fully functioning nuclear medicine ward). A concept of temporal separation of a full-care
and a no-care-ward is shown in [Fig. 1]. Second, positive evaluation by patients and students was biased by a dedicated
attitude of doctors, nurses and medicine physics experts who provided close support
to the students. Patients were carefully informed about the concept and thus, this
also contributed to a positive attitude towards their hospitalization.
Conclusion
We present a feasible and safe concept of using medical students instead of nursing
staff on a nuclear medicine ward. A selected group of patients without co-morbidities
requiring radioiodine therapy for benign thyroid diseases are highly satisfied with
the students’ performance. Students rate the work as predominantly positive as they
have the opportunity to gather experience, receive adequate salary and have time to
study during low-stress periods. This concept might even contribute to recruiting
medical doctors by providing deep insights into nuclear medicine.
