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4. Results from the IGRT review visits and physics IGRT support

4.1 IGRT review visit results

Each of the 50 NHS radiotherapy centres in England received an IGRT review visit from either one or both of the National IGRT Leads between 1st October 2012 and 30th May 2013 (Appendix 5). During this time 14 centres also received support from the NCAT IGRT physics support teams (Appendix 6).

By the end of the IGRT support programme all 50 centres had an IGRT MPT in place, which was an improvement on the initial survey finding of 42. However, this did not result in much overall improvement in the number of centres found to have clear roles and responsibilities for IGRT embedded within their departmental protocols and work instructions, with 12 of the initial 14 still needing to develop these.

Of the 50 centres that were visited, five did not have an adequate IGRT training programme in place. This result is an improvement on the reported responses from the initial survey. The majority of the remaining 45 centres still require significant development of certain aspects of their training programmes; in particular those that address the analysis and action processes of IGRT. Only 16 centres demonstrated complete training packages that addressed these key processes with adequate competency assessment strategies in place (Figure 3). Many centres only listed a limited number of staff with competence and IR(ME)R entitlement to review and accept image registration. As IGRT increases in use, in order to enable streamlined service delivery, it is essential that the number of staff with competence and IR(ME)R entitlement increase to meet service need.  Competency assessment must also be in place to meet this need with subsequent updates of staff  training records..

Centres were encouraged to approach the manufacturers for refresher applications training where it was identified that IGRT equipment had not been used clinically for a period of time following installation and commissioning. Image review and training programmes were reviewed in each centre and recommendations made where further development was needed.

Following discussion with members of the MPT during the IGRT review visits and the review of IGRT protocols it was identified that, at the time of writing, 39 centres were both justifying and recording concomitant imaging dose. The majority of the centres that were not recording imaging dose for each patient had measured the imaging dose during the commissioning process and were advised to begin recording this for each patient. Although recording imaging dose is a significant step forward, it is recognised that there is a wide range of practice (eg recording doses as number of scans, as mGy, as mSv, and whether dose is measured in phantom for a “standard” patient or tailored to individual patients). Work is required to achieve standardisation of approach.

The collection and analysis of patient set-up error data was not something that was asked during the initial survey and, as such, a comparison cannot be made. However, it was asked in an earlier NRIG IGRT survey conducted in 2011 prior to the publication of the NRIG IGRT report.1 The findings from the IGRT review visits were that 36 centres are now routinely collecting and beginning to perform trend analysis of this data to inform their own local practice (Figure 4) and in the majority of cases there is an MPT approach to this work.

Review of IGRT documentation during the IGRT review visits has highlighted a particular area of weakness in that only 56% (n=28) centres are performing regular risk assessments for IGRT.

4.2 Physics IGRT support results

Twenty one centres responded to the initial survey indicating that they would like to receive support. Following the IGRT lead visits and after follow up from the IGRT physics support team, those that had indicated that support was required through the survey but did not receive it stated that they were satisfied with their current position with regards to IGRT QA. By the end of the support programme, 14 centres had been provided with support from one of the physics support teams which was vendor specific.

The recurring themes for physics support were for validation of existing QA protocols, advice regarding image dose optimisation, data storage for volumetric imaging and the measurement, justification and recording of imaging dose.

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