Getting the Teams on Board & How to Safely Introduce New Techniques

Lisa Telford (00:04):

Hi. Good afternoon, everyone. I’m Lisa Telford, and Jane and I are both treatment delivery team leads at Preston. So we’re just going to talk about a few key tips that we use when implementing AlignRT and talk about one special group that we’ve recently done the mediastinal lymphomas for. So, very quickly, a brief overview of our department. Rosemary Cancer Center is in Preston in the northwest of England. We treat approximately 230 patients a day. We have eight machines, all Elekta, two that are in Harmony…There we go. Two that are Harmony, five that are Versa and one that’s being replaced to EVO at the moment. Our two CT scanners both have SimRT and all our treatment machines have AlignRT. And we have two remote systems as well that we use in data entry. All our systems were funded by Rosemary Cancer Charity.

Lisa Telford (01:02):

We went live in January 23. Yeah, so just a little further background as well. This is our radiographic staff. A majority of our staff are rotational because we’re so fortunate. We’ve got so many systems. I need all of these people trained for it to clinically work. So before we went live, we had a project team that was responsible for the rollout of SGRT in our department. That comprised of physicists, engineers, a clinician, radiographers from treatment and pretreatment and our planning team. And as a project group, we decided that the first site we would go live with was breasts. And this was primarily because we’d had a lot of problems with rescans resetting up breast patients. Like a lot of people, COVID came and the five fraction breasts came in great, but beam delivery was really long. So, doing breath hold, we weren’t confident.

Lisa Telford (01:58):

So we dropped breath-holding for this group of patients during COVID and we really wanted to pick it up. We’ve used the same approach on whatever site we’ve gone. So we’ve taken a small cohort check that we were happy with our workflow, and then implemented it for that cohort. We broke the breath down into all the different subcategories and starting with the first one, in a hundred clinical days, we had all our breasts, SGRT, and we dropped tattoos for this group of patients. We very, very quickly followed on to radical Thorax. And by this point, we now had two and a half linacs that we use in SGRT project team. We were delighted with where we’re at, and we got some audit data back. So we had some really good time savings in the three fractions, three fields, breath, but we also audited re-scan rates, re-imaging rates, and the time of imaging as well.

Lisa Telford (02:53):

The photon breasts are much quicker to image when we’ve used SGRT. So we’re really pleased with that. But our t our key tip really would be staff engagement. As I said before, we had a lot of radio geographies to get trained. So it started before we even had the systems aligned. My colleague did some in-house sessions about SGRT, what we learned at sessions like this, what we’d gone and seen in other departments, and what we were hoping to achieve in your super users. We brought one of our band sixes, again, reinforcing that support on the clinical floor. And then staff training, it’s really important to have your work instructions up to date. So we have an overarching competency for use of AlignRT and that makes it really easy to roll to the next site. We also have a troubleshooting guide, which has tips. So, allowing the radiographers to have that autonomous practice during those first steps of troubleshooting.

Lisa Telford (03:56):

Aside from this, we wanted to sort of tap into how the radiographers were feeling. So after we’d been clinical for a while, we sent out some surveys to just get some response back from them. We asked a multitude of questions. What was really clear was that both in sim and on treatment, the radio geographies were really confident using the system and crucial, which was the killer question, really. They felt it was easier to use AlignRT than conventional methods. What was really nice as well is things that the radiographer identified as benefits to the patient. So, no tattoosless manual handling were the things that we were trying to sell at the start. It was really nice that they actually saw that in practice. This was just a little bit more feedback. So we also asked them when they filled in the survey, just to see how long people were unqualified. Was there any difference between radiographers that being qualified a year and radiographers that being qualified for 20 years? We found no difference among the staff, but there were the same themes coming through, how quickly it was to get used to the system, how it feels like the system’s always been there.

Lisa Telford (04:59):

So we’d also ask the staff what site to visit next, and there had been mixed responses back. Pelvises, palliatives, we decided as a project team we were going to go with palliative as our next site for a couple of reasons. A, you get a lot of anatomical experience in there. We can flood our training because all the linac do some pelvic work. But most importantly, this is a group of patients who are in pain. So a quicker setup is a real benefit to them. A couple of interesting cases happen while we’re having this discussion. This lady here was a bilateral fungating breast treated with tangent pairs. Not strictly radical but not really a palliative setup. We used her with SGRT like we would with any tangent pair. And she set up really quickly in the last fraction, she was in that much pain. We were confident with the setup. We’ve been confident with the imaging. We admitted imaging for the last fraction.

Lisa Telford (05:52):

And I was called by the scanner team about this patient here. So she had one leg amputated again from gating lesion in pain. Where do you want tattoos? I don’t let’s SGRT. There were concerns about where the ROI would be in terms of stability, but really for this patient, I wanted the postural videoing. That was what’s going to help me on set. And you could imagine, you know, trying to read the comments that pretreatment has written about how to set her up. This was so much quicker. So I treated this lady and the radiographer who treated her instinctively knew when she got on the bed how to set her up. That’s how easy it is taken from one site with SGRT, to the next site. They just instinctively knew how to use the system to position this patient. We set her up, imaged her and treated her quicker than I got her on and off the bed.

Lisa Telford (06:42):

So it was a perfect case. Each time we’ve gone live as a project group, we’ve stopped reflected what we learned. These are some snapshots that we learned from the palliative patients. So when we had our training, we’d seen the FSD function, and we’d nod along and said, oh yeah, but we never really used it for the breasts or the thorax patients. But it really streamlines your workflow for palliative patients. The use of gated captures. Now we use it as standard for the thorax as you don’t need to, but for work construction purposes, it was easy to pull it in for the thorax. So when we were having the radiographers was seeing that there was some ROI instability over the breathing, they instinctively knew I’ll do a dated capture to capture that will resolve that issue. And the Postural Video is such a game-changer. It makes things so much easier to set up radiographers. We naturally want everyone straight. Then we take an image and realize they weren’t that straight, and scanner, postural videoing takes that away because you’re just reproducing that position.

Lisa Telford (07:44):

So where have we come? So in a couple of years we’ve done really well. We’re not quite up to Mike’s level, not fully there, but nearly we’ve got all our pelvic workload on. We don’t tattoo for breast thorax pelvis patients, palliative patients, whether we’re using bolus, not using bolus, we’ve got some of our SABR workload on. So we’re about 75% of our patients are treated using SGRT as the primary setup tool. Still a few things that we want to achieve. So we are currently trialling our open-face masks for SRS patients. We are actively looking to see what masks we’d like for head and neck patients. Very, very keen to get the SGRT on for the Sabre livers. That’s Jane’s goal. And the SABR spines and really going to what our goal was when we got this was to be fully SGRT.

Lisa Telford (08:37):

So just another key point about that staff engagement. You really need your team leaders to be involved because their confidence would radiate down to the staff, and a few little tips would really to get them engaged in here. So when I was over breast machines, I had eight work instructions for breast, whether they were breath hold and all the different subsections. There’s one. So when you have a new member of staff getting their competencies signed, it’s so much easier to move staff around the department. Like I said, taking one area from SGRT to the other area, once you know how the system works, it’s just so easy. So moving staff around from machines is easier, and stuff that have manual handling issues that perhaps can’t work on breast machines, you move patients so much less. So that’s much easier on the rotor. And just some last sort of tips.

Lisa Telford (09:26):

You need that initial project group for multidisciplinary work, but define your goal and that will vary. I appreciate that, depending on how many systems you have in your department, start that engagement with staff right from the start. Get the excitement going. Whatever site you choose to go with, take a small cohort, check that your workflow is correct, but don’t procrastinate. Move and go with that. Make sure your documentations update and keep updating any troubleshooting guides that you’ve got. Make sure you’ve got your super users to hand so you’ve got the confidence on the treatment floor audit to celebrate the work that you are doing. And that audit work can start now, before you’ve even got your systems, you can get your treatment time data. Great way to engage the staff. Everyone’s after a bit of CPD think about using SGRT for those challenging cases.

Lisa Telford (10:17):

So you may have two systems and think, right, I’m going to use it for breasts, but every patient can benefit from SGRT. So engage with pretreatment, engage with clinicians when they know there’s a patient who might be a difficult setup. We want to get away from health inequalities and this is a perfect system to allow to do it. It will also grow your confidence and help push your argument to move the workflow of SGRT forward. Celebrate all those successes internally, externally with alcohol, without alcohol, however you want to do it. And when you train more people or move to the next site, revisit those standards. Are people checking the Postural Video, are the ROIs as you said? Make sure that you’re just checking those standards throughout. So I’m going to hand over to Jane, and she’s going to talk about how we’ve been able to do this with the missing lymphomas.

Jayne Fletcher (11:14):

So yes, like Lisa said, my name is Jane and as a team leader we’ve been looking at implementing mediastinal lymphoma since roundabout 2023 when a clinician first mentioned it. So our current practice is probably similar to most centers without SGRT patients are in a closed face mask. Not really very conducive to you actually doing SGRT and breath hold. And what we decided we would do was, after the clinician first mentioned it, we started having some initial conversations. We thought let’s get on board with mediastinal lymphoma in DIBH And because we’ve got experience using the elect active breathing coordinator, that was our initial plan. Obviously, this was all pre-COVID, pre SGRT installation. And so we then had a brief pause, moved on to implementing SABR Liver and came back to it back in 2025 when our clinician turned around and said, I’ve got a patient for you, get ready. So a bit of a background into DIBH in the department. We started off pre-COVID with the non-assisted DIBH. Primarily on our two fielded left side. We got the electro ABC system started, using that for our SABR livers, and rolled it out to a few difficult cases in terms of lungs. We then got the AlignRT systems along with the RTC, and so we introduced that for our left-sided only. We have since rolled it out and are now doing the occasional right side but are hoping to continue that rollout so that we get all of our right sides in DIBH as well shortly.

Jayne Fletcher (13:07):

So like I say, our initial plan was will we use the ABC? Seems the best thing to do. It’s a gating system so we thought let’s, let’s have a look.

Jayne Fletcher (13:20):

It is time-consuming. It takes us about an hour to scan somebody and then an hour to treat them per session. And that’s because of the amount of coaching that the patients need in order to be able to regulate their breathing. And so we just looked at it, thought hmm, potentially 15 fractions within our with ABC that takes an hour is a lot of time on a linac to lose. We then had, by this point, a lot of experience doing DIBH using the RTC system. And so the easiest answer and the most obvious answer is let’s do it using AlignRT.

Jayne Fletcher (14:05):

So it has enabled us to reintroduce a breath-hold since COVID. We’ve also expanded, as I say to all of our left-sided patients with DIBH, and we are also now doing the occasional right side, as I’ve said, with the aim of us getting all of our right-sided patients on DIBH shortly. The RTC is very easy for patients to use. But you do come across the occasional patient who really struggles to understand what the screen is trying to show them. So actually, it’s not the easiest tool for everybody, but it works for about 90% of people, and even those patients that can’t tolerate having the screen above them and can’t understand it, still manage a breath hold using AlignRT. So we did have panic stations. The clinician, as I say, came to us with the patient and said, I’ve got one, let’s get ready, let’s get on with this patient. So, due to the fact that they have a family history of cardiac disease, it was quite important that we got this patient on DIBH, and if we weren’t able to treat them, they would’ve had to have gone to a different center which would’ve involved an extra hour’s drive for them.

Jayne Fletcher (15:24):

So we then had to look and see what was missing in our systems, what we needed to do to be able to get ready. And that involved having a consideration of immobilization what you do. Like we are at the moment use, we’re using closed face masks for any head and neck immobilization. So that wasn’t going to work for us. We’ve got our breath hold instructions from our DIBH patients and also from doing the liver ABC. So we were able to adapt that for the lymphoma like Lisa’s already mentioned, come up with your work instructions. We’ve already got competencies that we were able to adapt. We’ve got a troubleshooting guides that we were able to adapt and we got all of our quality system documentation done very quickly.

Jayne Fletcher (16:13):

One of the key things we looked at was trying to preemptively troubleshoot AlignRT. We know that we get occlusions at certain angles. We know that that was going to be a problem with a lymphoma patient who was in breath-hold. So what we did was get one of our very willing or not so willing colleagues to lie down on the bed and have a look and see what we could do. So having a look at where we would anticipate a mediastinal lymphoma isocenter to be, we decided along with our planning colleagues that we would try and situate the isocenter a little bit more anterior within the patient and also offset it superiorly so that the patient was further out from underneath the gantry head so that the cameras had more of the patient that they could visualize. I’m not going to say that trying to do that before a patient arrived has solved all of our problems, but it went a long way and helped us. We then had to think about like we’ve said occlusions defining an ROI, we had a good idea, we’ve got a lot of experience but it doesn’t always work out how you expect it to.

Jayne Fletcher (17:23):

So we had the first patient came in, we did the CT scan on him, we did a bit of coaching with him. You have to assess that they can manage the breath hold, hold it, understand instructions. And unfortunately because of the chemotherapy, this patient did have quite significant neuropathy. And so what we found was that although he managed to hold a pole for the CT scan during treatment, his hands were actually becoming very numb. So what we were able to do using the SGRT system was to drop his hands down slightly more behind the back of his head. And with the SRT system and postural video you could see that that wasn’t making any changes to his positioning. So we were happy to continue without needing to do any re-scan or re-plan. So just a quick look at the difference in his lung volumes to show the benefit that you do get from trying to treat patients like this. In breath hold, as you can see on the right hand slide with the lung volumes on it, it is considerably less volume than the breath hold scan. So we put an ROI on using our experience of thorax and breast, what we thought would look good, what we thought was going to work for us. And unfortunately, that wasn’t really the case when it actually came to the treatment session.

Jayne Fletcher (18:44):

So over the course of the first couple of treatments, we did amend the ROI considerably. Now this is due to the fact that when we tried to do a gated cap, sorry a capture post cone beam, the systems were coming up with quite an awful lot of black patches, which you can’t see on these slides here. But what we were able to do was use those black spots that it couldn’t see to then amend the ROI and cover everything that it could actually capture. We broke quite a few of AlignRT’s rules with this ROI and the fact that it isn’t over the ISIS center and it isn’t off the diaphragm. So with the Elekta system we used a fast acquisition. So it’s about a minute, about a minute of breath-holding for the acquisition to go around the patient managed it in two breath holds. If we had done this with the ABC system, it would’ve been three and a half breath holds to acquire a scan. So from the patient’s point of view it’s a lot less tiring for them to be able to manage.

Jayne Fletcher (19:58):

So just to show the image quality that you do get in being able to see these volumes when you have acquired your cone beam, obviously breath hold is going to always give you a better quality image but we were actually astounded as to the quality that we, that we managed to achieve. Especially as this is a fast acquisition. So as you can see, most of the anatomy that you would want to be looking at is very, very clear. Our clinician was also very impressed with the quality of these images. So we did then get a second case a couple of months later. Slightly younger gentleman, we tried due to the neuropathy in the first patients case we tried to put them in a body fix vac bag with their arm still up but a little bit more relaxed to hopefully help them feel a little bit more comfortable. Sadly that inter does interface slightly more with the ROI for the patient. So you do need to think about that when you are looking at your immobilization choices. Sadly, this patient had two fractions using the SRT system and due to his inability to be able to manage DIBH and achieve his breath-hold position it was a joint decision between the patient and the clinician that they would be re-scanned and re-planned free breathing in a mask as per our previous practice.

Jayne Fletcher (21:28):

So in terms of moving forward for us it is knowing that these patients are probably a wing board, nothing that’s going to be occluding space for an ROI, so not coming up and wrapping round the chest like a body fix probably would do our second case, our SimRT systems, because they were quite rotund in the stomach, if the SimRT had nothing that it could pick up on the patient. So you have to think about having a practice when you’re scanning them. That’s a little bit more old school that you can utilize. So we did manage to scan him. We used a manual breath hold and we got the two scans which is how we’d implemented our breast breath holds before we got SimRT. So we had experience with that as well. Think about your ROI adaptation with a lot of experience on SGRT. You can on the spot and on the fly, adapt your ROIs very quickly, and that’s where having super users but staff that feel very confident with the system, who have got lots of experience and have used it for multiple sites, they all feel more confident in being able to adjust an ROI using our previous DIBH experience.

Jayne Fletcher (22:39):

We’ve got the competencies for breast DIBH and we’ve got competencies for thorax. So we were able to sign a lot of our staff off very quickly with this system. If we had used the ABC, we would currently only have 20 staff signed off to use ABC due to its infrequent use. So it would’ve been a lot more of a training burden to get more staff trained. And then, like Lisa sort of mentioned, it’s then thinking about how you use this, even this experience with DIBH for the lymphomas in how we roll out to even more sites. So our, our current plan is looking at the livers and hopefully getting our spines, SABR spines on SGRT as well. So yeah, from Lisa and me, thank you very much, and we would just like to thank all of the staff at Rosemary Cancer Center for their ongoing support and really their speedy adaptation. And as radiographers, we don’t always accept change very quickly, but our guys have really taken it on board and have flown with it. So thank you very much.