Kate Bak

Organisational standards for the delivery of intensity-modulated radiation therapy in Ontario.

By minimising the effect of irradiation on surrounding tissue, intensity-modulated radiation therapy (IMRT) can deliver higher, more effective doses to the targeted tumour site, minimising treatment-related morbidity and possibly improving cancer control and cure. A multidisciplinary IMRT Expert Panel was convened to develop the organisational standards for the delivery of IMRT. The systematic literature search used MEDLINE, EMBASE, the Cochrane Database, the National Guidelines Clearing House and the Health Technology Assessment Database. An environmental scan of unpublished literature used the Google search engine to review the websites of key organisations, cancer agencies/centres and vendor sites in Canada, the USA, Australia and Europe. In total, 22 relevant guidance documents were identified; 12 from the published literature and 10 from the environmental scan. Professional and organisational standards for the provision of IMRT were developed through the analysis of this evidence and the consensus opinion of the IMRT Expert Panel. The resulting standards address the following domains: planning of new IMRT programmes, practice setting requirements, tools, devices and equipment requirements; professional training requirements; role of personnel; and requirements for quality assurance and safety. Here the IMRT Expert Panel offers organisational and professional standards for the delivery of IMRT, with the intent of promoting innovation, improving access and enhancing patient care.

Delivery of Brachytherapy for Cervical Cancer: Organisational and Technical Advice to Facilitate High-quality Care

AIMS Brachytherapy is a standard therapy for cervical cancer; it allows for the delivery of a high dose of radiation to the tumour while sparing the surrounding healthy tissues. With this document, the Brachytherapy Cervical Cancer Expert Working Group (BCCEWG) aimed to provide advice on organisational and technical aspects of the delivery of brachytherapy services in Ontario, Canada. MATERIALS AND METHODS We sought technical documents, practice guidelines and standards through an environmental scan of internet resources, an iterative search of the literature on MEDLINE and EMBASE, and a search of reference lists of included documents. RESULTS We identified 20 guidance documents authored by 10 organisations; 11 documents were identified through the environmental scan, five through the literature search and four from reference lists. The recommendations included in this document were developed by the BCCEWG through the selection and review of the evidence and informal consensus. CONCLUSIONS These organisational recommendations aim to set the stage for high-quality delivery of brachytherapy for cervical cancer services in the province of Ontario, Canada. They address the characteristics of the practice setting, including facilities, equipment, delivery suite, imaging technologies, treatment planning and dosimetry; the practice team, including team members, roles, training, team caseload/volumes and qualifications; and the quality assurance domain, including documentation, audit, safety and quality control.

Use of Continuous Infusion Pumps During Radiation Treatment

INTRODUCTION Despite increasing chemoradiotherapy treatment, there is a paucity of information regarding the effects of radiation exposure on ambulatory infusion pumps used to deliver chemotherapy or other essential medications. The aim of this overview is to present the available evidence on this subject, heighten awareness within the clinical community, provide considerations for minimizing possible negative effects on patient care, and encourage the monitoring of infusion devices after exposure to radiation or electromagnetic interference. METHODS Published literature was systematically searched using MEDLINE and EMBASE; gray literature was searched using Google and an environmental scan of relevant Web sites. A multidisciplinary working group reviewed the compiled evidence, and a draft of the document was sent to health professionals from various disciplines for an external review. RESULTS Four reports and three manufacturer device alerts were identified that suggest a risk of pump malfunction as a result of radiation exposure. The estimated cumulative dose at which pump failure has been reported ranges from 28.5 to 42 Gy; however, additional clinical investigations should be undertaken. Pump relocation, pump shielding, and assessment of the pump after radiation exposure are most commonly suggested to minimize pump malfunction related to radiation exposure. A list of additional considerations is offered for those developing institution specific policies and procedures based on the available evidence and expert consensus. CONCLUSION The varied and unpredictable results of radiation exposure on infusion devices suggest that additional testing should be carried out to determine the limits of dose exposure and to raise awareness around this patient safety issue.

Collaborating with Ontario cancer centers to ensure coordinated access to safe, evidence-based, high-quality IMRT treatment.

187 Background: In 2007, CCO identified variability in access to Intensity Modulated Radiation Therapy (IMRT) across the province. To ensure access to this technology, a three-year IMRT implementation Project was started in 2008, focusing on the development of: disease site guidelines and targets, cost-effectiveness analyses, a provincial quality assurance program, disease and discipline specific communities of practice and knowledge-sharing platforms. METHODS Needs assessments were conducted to identify educational and training needs in all disciplines. Systematic reviews were undertaken to establish disease site specific IMRT indications, set targets and conduct cost effective analyses. Educational courses and hands on expert-based coaching, were made available and a provincial IMRT quality assurance program was established. RESULTS The needs assessments identified a strong interest in educational and coaching opportunities. IMRT indication guidelines were developed for 10 disease sites and utilization targets were set for 6 disease sites. Results from two cost effectiveness analyses confirmed IMRT as a standard of care over 3D Conformal Radiation Therapy. 11 cancer centres received IMRT expert-based coaching, which included hands on-training, site visits, and educational support. Knowledge sharing and educational opportunities were provided to over 949 radiation therapists, oncologists and physicists. 13 cancer centres participated in external IMRT quality assurance testing for head and neck and prostate cancer. IMRT utilization has increased without affecting wait times or patient safety with no increase in incidents during this time period. All six disease sites have me their targets for 2012/13. CONCLUSIONS IMRT knowledge and expertise across the province has grown along with a dramatic increase in the percentage of patients being treated for curative intent receiving IMRT. This jurisdictional implementation project was successful in making this treatment available to all Ontarians who would benefit. The lessons learned from this experience may be useful in the future rollout of other new technologies in Ontario and in other health care settings.

The Clinical Specialist Radiation Therapist (CSRT): A case study exploring the effectiveness of a new advanced practice role in Canada

The Clinical Specialist Radiation Therapist (CSRT), is a new advanced practice (AP) role for radiation therapists (RTTs). Following training, education and evaluation, the CSRT performs specific duties in autonomous ways, making advanced clinical decisions in their area of specialization. This case study examines the CSRTs impact on quantity (i.e., increasing capacity), improving quality and stimulating research and innovation.

Best Practice Recommendations for the Retention of Radiotherapy Records

This paper offers best practice recommendations for the maintenance and retention of radiotherapy health records and technical information for cancer programmes. The recommendations are based on a review of the published and grey literature, feedback from key informants from seven countries and expert consensus. Ideally, complete health records should be retained for 5 years beyond the patients lifetime, regardless of where they are created and maintained. Technical information constituting the radiotherapy plan should also be retained beyond the patients lifetime for 5 years, including the primary images, contours of delineated targets and critical organs, dose distributions and other radiotherapy plan objects. There have been increased data storage and access requirements to support modern image-guided radiotherapy. Therefore, the proposed recommendations represent an ideal state of radiotherapy record retention to facilitate ongoing safe and effective care for patients as well as meaningful and informed retrospective research and policy development.

179: It's Crunch Time: Finding Efficiencies With a New; APRT-mediated Model of Care

withdrawn 181 PATIENT EXPERIENCE SURVEY OF EARLY-STAGE BREAST CANCER PATIENTS UNDERGOING WHOLE BREAST RADIOTHERAPY Grace Lee, Robert Dinniwell, Anthony Fyles, Tatiana Conrad, Kathy Han, Wilfred Levin, Fei-Fei Liu, Susanne Lofgren, Alexandra Koch-Fitsialos, Gerald Devins, Nora Emad, Bethany Pitcher, Tony Panzarella, Anne Koch Princess Margaret Cancer Centre, Toronto, ON University of Toronto, Toronto, ON Purpose: Adjuvant breast radiotherapy (RT) is a standard treatment option in women with early-stage breast cancer following lumpectomy. Timeliness of RT treatment can impact patient satisfaction. The objectives of this study are to assess: 1) patient satisfaction of their whole breast RT; 2) patient preference for timing of RT start after CT simulation (CTSim); and 3) factors that influence patient stress and quality of life. Methods and Materials: Women undergoing whole breast RT were given a survey before RT treatment and at treatment completion. Patients were offered treatment either through the conventional process (ConvProcess), where RT starts typically within 1-2 weeks of CTSim, or the QuickStart (QS) process, where RT starts one day after CTSim. The pre-treatment (PRE-Tx) survey included questions to understand the social impact of RT, and the post-treatment (POST-Tx) survey included questions relating to social climate and patient satisfaction. Questions relating to RT start preference, stress (Perceived Stress Scale [PSS]) and quality of life (Illness Intrusiveness Ratings Scale [IIRS]), were assessed both at PRE-Tx and POST-Tx. An analysis of covariance was used to determine if the RT process impacted PSS and IIRS, and t-tests were used as a secondary analysis. Fisher’s Exact test was used where appropriate. Results: Ninety-six patients completed the PRE-Tx survey and 88 completed both surveys (QS process n = 28; ConvProcess n = 60). All patients indicated they had a positive experience with the RT

Using the experience-based design (EBD) approach to strengthen patients’ impact.

69 Background: The Experience Based Design (EBD) approach uses patient and clinician experiences to identify opportunities for improvement in the healthcare system. The EBD approach elicits subjective and personal patient, carer, and staff experiences at crucial points in the care pathway by encouraging them to share their stories. METHODS Cancer Care Ontario (CCO), an agency that oversees cancer services in Ontario, held an EBD workshop with the objectives of capacity building and facilitating healthcare improvements throughout the province. 110 participants (27 teams) from across Ontario attended the workshop to engage participants to take an active role in developing actionable plans to address patient experience issues. An evaluation following two years of EBD was necessary to: (a) determine EBD progress and effectiveness; (b) identify successes/challenges for getting projects off the ground; and (c) identify additional resources required to spread EBD across Ontario. The evaluation consisted of: 1) two province-wide electronic surveys (long survey for those directly involved in EBD projects; short survey for frontline staff) and 2) semi-structured phone interviews with patients/caregivers. RESULTS Some EBD projects have completed multiple initiatives; others are just beginning. Projects address process improvement (e.g., streamlining patient bookings), resource/tool development (e.g., symptom screening tools) and establishing patient advisory boards and committees. Five (28%) survey respondents said that EBD projects elicited implementation of 6 to 10 changes and 6 (38%) respondents indicated that: (1) respect for patient preferences and (2) communication, information and education were two principles of Person-Centred Care (PCC) that improved the most. CONCLUSIONS Future steps include development of a collaborative website, a symposium to showcase projects, an evaluation of the EBD initiative and peer-reviewed publication.

IMRT utilization in Ontario: qualitative deployment evaluation

PURPOSE The purpose of this paper is to describe a jurisdiction-wide implementation and evaluation of intensity-modulated radiation therapy (IMRT) in Ontario, Canada, highlighting innovative strategies and lessons learned. DESIGN/METHODOLOGY/APPROACH To obtain an accurate provincial representation, six cancer centres were chosen (based on their IMRT utilization, geography, population, academic affiliation and size) for an in-depth evaluation. At each cancer centre semi-structured, key informant interviews were conducted with senior administrators. An electronic survey, consisting of 40 questions, was also developed and distributed to all cancer centres in Ontario. FINDINGS In total, 21 respondents participated in the interviews and a total of 266 electronic surveys were returned. Funding allocation, guidelines and utilization targets, expert coaching and educational activities were identified as effective implementation strategies. The implementation allowed for hands-on training, an exchange of knowledge and expertise and the sharing of responsibility. Future implementation initiatives could be improved by creating stronger avenues for clear, continuing and comprehensive communication at all stages to increase awareness, garner support and encourage participation and encouraging expert-based coaching. IMRT utilization for has increased without affecting wait times or safety (from fiscal year 2008/2009 to 2012/2013 absolute increased change: prostate 46, thyroid 36, head and neck 29, sarcoma 30, and CNS 32 per cent). ORIGINALITY/VALUE This multifaceted, jurisdiction-wide approach has been successful in implementing guideline recommended IMRT into standard practice. The expert based coaching initiative, in particular presents a novel training approach for those who are implementing complex techniques. This paper will be of interest to those exploring ways to fund, implement and sustain complex and evolving technologies.