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8. Recommendations

8.1 Radiotherapy service providers

Recommendations were presented to centres after the visit within a formal report; criteria were measured in each centre and the gap between actual and desired assessed.

8.1.1    Environment

  • The design of treatment control areas need to be reviewed so that lighting levels can be adjusted to optimise contrast within the image.  Minimising interruptions and distractions in these areas is essential.

8.1.2   MPTs

  • IGRT MPTs must ensure there is an IGRT strategy to support future developments.
  • Multi-professional working must be enhanced and skills used appropriately, including developing radiographer-led image review.
  • There needs to be collaboration between the MPT’s during linear accelerator and CT scanner replacement. There is potential for the development of novel roles in commissioning. 
  • A scope of practice for the advanced imaging radiographer role should be created to define and justify the responsibilities of this role.
  • Risk assessments must be completed when implementing new technology and techniques. This is made clear in the NRIG IGRT report.1

8.1.3   Protocols

  • The roles and responsibilities within clinical and local IRMER protocols  need to be accurate and reflect updated IGRT training and entitlement to act in IRMER roles.  Protocols must be reviewed for those individuals justifying non-planned imaging dose to ensure they are in-line with IR(ME)R Legislation and guidance. 2,3
  • The use of document templates is recommended to ensure continuity in the format of local protocols and work instructions.

8.1.4  Training

  • All providers to have access to and use the e-LfH IGRT module 4 as part of local training and competency programmes.
  • Training workbooks for MV/kV planar imaging and 3D volumetric imaging are desirable. Training records for IGRT under IRMER must be updated too. There are key components: these should include;
    • Mandatory reading of policy documents and work instructions/protocols.
    • Educational component to include equipment functionality, image quality and image artefacts, dosimetry teaching regarding contour change and anatomical anomalies, evaluation of image review accuracy and CT anatomy interpretation testing.
  • Investigate strategies for expediting IGRT training as a stop gap that may include training out of clinical hours or during machine service time.
  • A database of interesting patient cases that can be used as a training aid to help assess troubleshooting skills should be compiled.
  • Developments in applications training must be driven by service providers and reflect local pathway requirements (also see 8.5 below).
  • Protected time needs to be provided for the IGRT team including the lead imaging radiographers, clinical radiographers and physicists to enable the development and implementation of IGRT training programmes as recommended in the NRIG IGRT report.1
  • Introduce a simple competency based training matrix.

8.1.5   Imaging doses

  • IRMER requires that an assessment of patient dose is undertaken. Imaging doses should be recorded for each patient as a total concomitant exposure received during planning and treatment (Regulation7, 3(b) of IRMER).
  • Further work is required to ensure consistency in approach between pre-treatment and treatment imaging and between centres. It is suggested this may be a role for the IPEM interdepartmental audit group.

8.1.6   Equipment

  • The commissioning of all imaging equipment should be completed to enable image-guided intensity modulated radiotherapy (IG-IMRT) to be utilised effectively while reducing appointment times.

8.1.7   Imaging

  • Image review must become competency and not grade-based as this will enable a more efficient and flexible service.

8.1.8    Audit            

  • Consider the introduction of regular audit of intra and inter user variability in image matching.
  • Audit of patient set up error data must become routine practice to help inform local planning margins and justify on-treatment image verification frequency.

8.2     NHS England Specialised Commissioning

  • Clearer guidance for IGRT tariffs is required, in particular that which relates to the use of the ‘Adaptive’ code Y91.4.
  • A new code is required for IGRT linked to levels of complexity as outlined in the NRIG IGRT report.1
  • Future guidance relating to IGRT coding needs to be less ambiguous to avoid misinterpretation and to ensure its application is standardised.
  • The IGRT Commissioning for Quality and Innovation (CQUIN) would benefit from being reviewed so that it becomes more prescriptive allowing it to be interpreted consistently by all service providers.

8.3     Radiotherapy education providers

  • Radiotherapy service providers must work with local Higher Education Institutions in developing the minimum requirements to enable new radiographers to be fit for purpose as outlined in the Education and Career Framework.5
  • Volumetric image analysis and decision making skills need to be developed during undergraduate and post graduate pre-registration programmes via a standardised IGRT curriculum.
  • All education providers are advised to adopt the IGRT training framework outlined in Appendix 7.

8.4     Radiotherapy board (Joint professional bodies: SCoR, IPEM, RCR)

  • It is essential that the professional bodies continue to work together to support the work that had been funded by NCAT, so as not to lose the momentum of change that has been established.
  • A follow-up survey to assess the progress that has been achieved with regards to IGRT implementation is advisable after 12 months.
  • There is an appetite for improved physics IGRT support and physicists are encouraged to utilise the medical-physics-engineering@jiscmail.ac.uk  listserver and RT imaging SIG ‘Google’ forum established by the SCoR.

8.5     Radiotherapy equipment manufacturers

  • Applications support needs to include anonymised data sets or possible access to on-line web demonstrations (modular e-learning) for group learning and discussion of non-standard cases for training, reducing the use of phantoms.
  • Follow-up visits or annual training updates.
  • Remote terminal access for off-line review and IGRT training.
  • Access to data for systematic error and population trend analysis, including statistical analysis tools must be made available.
  • More in depth training regarding registration algorithms and training in image analysis and QA was requested by physicists.

8.6     Radiotherapy trials

  • The IGRT component of any trial methodology must be clear and work must continue with the RTTQA group in developing an accreditation method for IGRT that is anatomically site-specific.

National IGRT Team

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