Thinking Differently About the Kids: An Innovative Approach to Improve Care Provided to Pediatric Patients Undergoing External Beam Radiation Therapy.

AIM: This article reports the changes made from 2009-2012 to the external beam radiation therapy (EBRT) preparation and treatment process provided to pediatric patients at the Tom Baker Cancer Center (TBCC) Calgary, Alberta, Canada. BACKGROUND: The number of pediatric patients referred for EBRT at the TBCC doubled between the years 2008 (15 patients) and 2011 (30 patients). This increase in patient numbers prompted the staff of radiation therapists to evaluate the department's EBRT preparation and treatment process for pediatric patients. DATA SOURCES: A literature search was performed to obtain data and research findings that described pediatric care processes adopted by EBRT programs in Canada and other countries. A pediatric working group (PWG) was assembled at the TBCC, which identified two areas for internal review and evaluation. The PWG critically reviewed the process of determining the delivery of treatment under sedation versus nonsedation and reviewed and evaluated the current play therapy and educational tools used to reduce the anxiety of children and parents concerning EBRT. CONCLUSIONS: The presence of a radiation therapist at each new patient pediatric consult resulted in positive effects in the management of the patient's journey through EBRT. The application of the Pediatric Care Pathway Assessment Tool at the time of consult helped to identify patients requiring sedation versus nonsedation for treatment. The implementation of play therapy sessions before the start of treatment in combination with the use of audiovisual aids during EBRT reduced the requirement of sedation for treatment. A time motion log was found to be an appropriate tool for measuring the amount of time a patient spends in the department and helped to validate the placement of the patient on the sedation or non-sedation pathway.

Implementation of Lung Stereotactic Ablative Radiotherapy at a Regional Cancer Centre.

BACKGROUND: For patients with inoperable Stage I (T1-T2, N0, M0) non-small-cell lung cancer, stereotactic ablative radiotherapy (SABR), also known as stereotactic body radiation therapy (SBRT), has demonstrated survival outcomes similar to surgery. Lung SABR is a technically challenging means of delivering precise, high-dose radiation to a small tumor volume. At many cancer centres, the widespread use of SABR is impeded by the complexity of the implementation process. This study will aim to provide a detailed guide to the steps involved in delivering lung SABR in a reliable and efficient manner. PROCESS: The execution of this intricate treatment program at our cancer centre required the collaboration of a multidisciplinary team. Input from several professionals within radiation oncology was necessary, including medical physicists, dosimetrists, radiation therapists, nurses, and radiation oncologists. Expert guidelines have been developed which give careful consideration to each step of the process, including 1) reliable and reproducible patient immobilization, 2) a method to account for tumor and organ motion, 3) the use of multiple treatment fields to deliver highly conformal radiation dose with a rapid dose fall off, 4) daily imaging that allows for repositioning from simulation to treatment, 5) accurate and precise dose-calculation algorithms, and 6) a vigorous quality assurance program. Lung SABR was introduced at our centre in 2007 and thus far 92 patients have been treated. There are currently three treatment machines capable of performing this procedure. BENEFITS/CHALLENGES: Patient immobilization through the use of body cushions, accurate tumor and organ delineation via the use of four-dimensional computed tomography simulation, development of firm treatment planning guidelines, treatment verification using cone beam computed tomography, and a robust quality assurance program have all been instrumental in ensuring the safe and effective delivery of lung SABR. However, the process was laden with challenges, from delineating the optimum immobilization technique that balances patient comfort and motion, to introducing ways of making novice staff comfortable with a new method for treatment verification. CONCLUSIONS: There are outcome and toxicity data being collected on patients undergoing lung SABR at our cancer centre. This will serve as a self-assessment tool for our implementation process. Moreover, as future indications for SABR change, this initial implementation step will serve as a framework on which to continue building comprehensive guidelines.

Validating the Selection of Quality Indicators for Venipuncture Procedures Performed in a Radiation Therapy Department.

PURPOSE: An extensive literature review was completed to validate the selection of quality indicators for venipuncture procedures performed in a radiation therapy department. METHODS: A retrospective quantitative study (2007-2010) was conducted at the Tom Baker Cancer Center (TBCC) to review the data captured on a quality control log/statistical template for 900 venipuncture procedures performed in the radiation treatment program (RTP). The quality indicators for the venipuncture program had previously been identified to include the collection and monitoring of: the frequency/occurrence of adverse events, identifying the type of adverse events, and the number of attempts required to obtain venous access. There were no patient identifiers recorded on the department log/statistical template. RESULTS: Data extracted from the TBCC RTP quality control log in 2007-2010 revealed an incidence of five extravasations events and one air embolism event. Comparison of the published adverse events and rates in the literature to the TBCC RTP venipuncture program rates show that its recorded quality control log/statistical template is targeting the appropriate categories. The literature reported, on average, rates for extravasations to be between 0.04% and 1.3% compared with the TBCC RT department's 0.56%. The occurrence of air embolism rates in the literature was reported to be between 11.7% and 23% compared with 0.11% occurrence in the TBCC RTP department. Based on the evidence reported in the literature, other quality control indicators have been incorporated into the TBCC RTP venipuncture program. The TBCC RTP expanded the venipuncture program quality control log/statistical template to collect and monitor the occurrence rates of phlebitis, hematoma/bruising, nerve, tendon and/or ligament damage, and infection. CONCLUSION: The creation of standardized quality indicators for radiation treatment programs performing venipuncture in all health care facilities performing venipuncture would 1) be a step in maximizing patient safety and improving quality of care and 2) provide an opportunity for institutions to gauge and compare the quality of care provided using the same quality indicators for health care institutes performing venipuncture procedures. Collaboration with other facilities to identify, monitor, and report the data collected from standardized quality indicators would result in an increase of knowledge concerning the occurrence of rates of adverse events during and after venipuncture procedures performed in a radiation therapy department. Such efforts can only lead to increased quality of care provided across the health care system.

A Radiation Therapy Venipuncture Certification Education Program.

The Tom Baker Cancer Center (TBCC) is located in Calgary, Alberta, and employs 80 radiation therapists. The province of Alberta currently has two facilities that offer radiation therapy services. In 2006-2007, approximately 2,800 new and repeat patients received care at the TBCC. The Radiation Treatment Program (RTP) annually performs between 220 and 240 intravenous procedures using contrast media. Radiation therapists are licensed to practice through the Alberta College of Medical Diagnostic and Therapeutic Technologists (ACMDTT). In 2007, a radiation therapy venipuncture certification process was developed to implement an extended role for radiation therapists, allowing them to perform venipuncture. Using an algorithm as a design tool, the RTP radiation therapist educators created a locally based education and experiential learning certification program for radiation therapists endorsed by the RTP administration and the ACMDTT. Included in this article is a description and explanation of the algorithm design, an outline of the RTP radiation therapy venipuncture certification process, and a discussion on possible future research areas to further support the validity of an algorithm as a design tool.