Top Tips for Effective and Efficient SGRT Implementation

So I’m Sarah Wisniewski. This is Sarah Cummings. We are the Sarahs. And so today we will be talking to you about the “Top Tips for Effective and Efficient SGRT Implementation,” keeping with the theme of efficiency. Sarah one, Sarah two, physics Sarah, therapist Sarah.

All right, perfect. So to begin, no conflicts of interest for either of us to disclose, but of course, as many other speakers have mentioned, our travel was supported by VisionRT, so we’re very thankful for the opportunity to come speak to you guys today. And then I also just wanted to add a disclaimer about the photos. None of the photos you see are real patients. We either acquired them ourselves on our friends’ setup, or we generated them through AI.

All right, as far as the outline. So physics Sarah will be talking about the physics and QA-focused topics. So these are going to be things like building the case. So with this being the new users track, I know a lot of you guys are probably looking to purchase SGRT, so I wanted to help you through that process. Commissioning strategy. As a physicist, how could I not talk about commissioning strategy? Workflow design and integration, I think the best example is DIBH, so we’ll talk about that. And then, of course, establishing your QA program. And then therapist Sarah will talk about therapist-focused topics. So these are going to be things like building a training and competency program, communication and education of patients, breast/chest DIBH, and then expanding to other sites.

All right. So because we’re talking about tips and tricks, I think it’s really important for you guys to know a little bit about us, where we’re coming from to give you these tips and tricks. So we are with Novant Health. Novant Health has hospitals all across the Carolinas. We are at the Winston-Salem location, which I’ve highlighted there. Our market consists of two sites. We have the main campus, which is where we are usually located, but we also have a satellite site about 20 minutes to our east. We have four TrueBeams and a VitalBeam across our sites. We use Aria and Eclipse. And then as far as SGRT, we have VisionRT using SimRT and AlignRT. We are fully markless for all non-masked sites. We also use this as our primary setup tool for quite literally everything. And that includes, for us, 3D, IMRT, VMAT, SBRT, SRS, and even VMAT TBI.

All right, so let’s talk about building the case a little bit. So step by step, I want to take you through the process of what it might look like for you pitching buying SGRT. And so with new technology, I personally like to make the recommendation that you want to start with what problems you’re trying to solve with the technology, not just like, “There’s this flashy new technology that I want,” but, “Here are the problems we experience in our clinic that this could help with.” And so this is things like setup time. You want to improve your efficiency and set up patients faster. It’s things like wanting to be more efficient and accurate with treating DIBH and SRS. Can we do more intrafraction monitoring without actually doing intrafraction imaging? And you might have an issue with extensive imaging and re-imaging. You want to reduce the imaging dose to your patients. SGRT can allow you to do that. So you’ve heard many other examples of things that SGRT can be useful in other sessions, so I won’t belabor those, but these are just a few examples of ways you could also frame that.

Next, focus on the high-impact use cases. So you want to start small and work your way up. So this is that kind of piecewise implementation that I’m sure you’ve heard a couple of times from the other presentations. So for us, this was focusing on DIBH and SRS. These were our two use cases that we personally started off with when we implemented SGRT in our own clinics.

And then, of course, what’s a purchase without lobbying, right? You’re going to have to lobby for this. So tailor the message to the various stakeholders. Talk to your MDs. Tell them, “Here’s why I think this is going to be valuable for your patients.” Talk to your therapists about saying, “Here’s how it’s going to improve your day-to-day life.” Your physicists: talk about how it’s going to help actually monitor intrafraction motion in a better way than just imaging dose. So lobby for exactly what you’re looking for with this software.

And then, of course, nothing’s perfect. And so you don’t want surprises. When you make a purchase like this and people start to implement it, you don’t want them to be surprised with the things that don’t go right. So be truthful about the things that might not go right with these things. So for example, that’s things like we’re really only monitoring the surface. You get no representation of the true internal mark of motion. Things like the limited field of view. So for example, in our clinic, we do prostate SBRT with triggered imaging. Those arms are pretty much constantly blocking a camera. So we will keep AlignRT on while we are treating those, but we won’t gate with those. So just a common workflow efficiency thing that you should also be aware of. Lastly, ROI accuracy. So again, I won’t belabor it. We’ve talked about it a lot. But it is only as accurate as the ROI you are drawing. So these are some of the things that you should also be aware of as you are talking to people about what you’re actually going to be implementing.

And then I don’t want to talk about the therapist things because that’s what therapist Sarah’s going to do. So she’ll talk about those after I am finished. My key tip, though, for building the case is essentially you want to sell the problem, not the technology, right? What can you do to improve your clinic? What problems are you solving, and what does the technology help you do there?

All right. So commissioning strategy. Again, we had a really great presentation as far as what to expect with commissioning, so I don’t want to go into too much detail. But as far as my envisioned commissioning strategy for an SGRT system, these are the steps that you would have to take. You have, of course, installation and calibration. You have the geometric accuracy testing. You have motion detection, workflow design, and of course, an end-to-end. And so just to have the reference in case anyone needs it, we have the glorious TG-302, which has an outline of various things that need to be done during commissioning. And so basically, if you have this, you know what you got to do, which is great. But you don’t have my key tip. And my key tip is, first verify your accuracy before you test your workflows and your end to end. If the system is not set up appropriately and is not accurate in the beginning, you’re just going to compound your uncertainties by the time you get to the end to end. So make sure you are doing validations throughout the process of commissioning, not just getting to the very end and kind of expecting things are going to work out well.

And I think the best actual workflow design to go through to explain what to expect with SGRT use case is DIBH, right? And so as far as what this looked like for integrating with us in our own clinics, we started by using the SGRT in tandem with our existing workflows. So this allows you to gain familiarity with the system and not overwhelm people with actively trying to use it as your new primary system. So for us, this was, we would treat free-breathing and DIBH patients, just have AlignRT on in the background. Therapists could use it. They would monitor how to set up the patient, see when they wanted to choose to use it. This also allowed us to see where in our workflow we felt SGRT would be the most helpful. So once you do that, you can gradually move towards actually using it for free breathing. And so this allows you to then improve your efficiency and setup. Again, we’ve had a lot of reports cited today that shows how this does improve your efficiency. So actually get that feeling now. Use it, improve your efficiency. It also allows you to take the time to establish some of these guidelines for your clinic as you move towards implementing this system in your own clinic. So for example, for us, this allowed us to say, “Okay, if I’m now using this SGRT system and it shows my patient goes out of alignment, what do I do?” And so we’ve established these intrafraction re-imaging tolerances for our therapists, so they know exactly what to do when something happens. So I wanted to have that here for you guys to look at if you needed it. This is just our departmental guidelines.

Now you get to finally treat using SGRT for your DIBHs. So now that you’ve gotten comfortable setting up your patients in free breathing, there’s a couple things you now need to do to move towards this DIBH. So this allows you to establish guidelines for patients that are good candidates for the deep inspiration breath hold. It allows you to now add a DIBH scan at SIM. You practically have to now acquire a whole new scan. So you need to set up those parameters and protocols. You will now have a new positioning workflow. Your therapists have been used to setting up patients in free breathing. Well, continue to set up your patient in free breathing and then fine tune with DIBH. So an additional step. And then lastly, your therapist might not be familiar with the various coaching strategies to get your patients exactly where they need to be in that breath hold. So your therapist now learning that process as well. So by doing this piecewise approach, it’s more digestible for your therapist and your team.

And then, of course, one additional step would be you might have some DIBH cases with bolus. What types of boluses are you using? Does the SGRT system pick them up well? It might not. You might need to change the bolus. You might need to come up with a new workflow for when it doesn’t detect the bolus well, and your therapists need to get familiar with moving between different surfaces. You might have fields that have a bolus and fields that don’t have a bolus. So kind of learning that workflow and gaining that familiarity would be the final step in treating all kinds of DIBH patients. So my key tip here would be the SGRT isn’t replacing your judgment, it’s just additional information. Use it that way, and then you’ll see that your treatments get more efficient and more effective.

And then lastly, I wouldn’t be a good physicist if I didn’t talk about establishing a QA program. And so again, TG 302 does a great job of outlining the various tests that you need to do, so I don’t want to go over that too much. But my key tip is talking about integrating what you’re required to do within your existing QA. And so an example I have for you guys is in our monthly QA, we’re still doing monthly outputs with solid water and an ion chamber. So I’ve got a little video here showing you how we now test beam gating with our SGRT system. Same solid water setup, same ion chamber, but now I’m going to measure over the delivery of a beam where I make the gate happen. Essentially, I simulate a fake couch kick that’s not going to happen to throw the system out of alignment and to pause the beam. So I use the exact same 10 by 10, 100 MUs, 100 cm SSD, and I measure that, and I make sure it matches my non-gated beam. So just a really efficient, easy way to set up your QA systems and make sure things are working well. So key tip, design tests that integrate within your existing QA for maximum efficiency. And I will go ahead and hand this off to Therapist Sarah.

Hi, everyone. I’m Therapist Sarah. So I’m going to go over the more treatment side of everything. So we just switch gears from all the physics fun to the treatment fun. So my first tip is talking about building a training and competency program. This is more geared toward the therapist side of things.

Like we’ve heard multiple times is that the super users or champions, as everybody keeps calling them, is the backbone of the implementation process. You want to identify a core group of experienced therapists to be the ones that want to volunteer to do the training with the vendor, work with troubleshooting, figure out how to use it, and deep dive into it. And at our center, the super users also help come up with some tip sheets. They created the tip sheets that they keep at the machines. So if they ever had a question or anything, they could just reference the quick sheet. “Oh, I need to click pause before I need to capture my SSDs.” Those are really helpful.

So once they become the trainers in the workflow, figure out all that thing for their training of staff, they are the go-to people. So now it’s a peer training versus having somebody you don’t know as well, but somebody who knows your workflow, integrates it into your daily, ideally how it can be more efficient in your workflow for your treatment machine. When it came to training the staff, you want to be intentional with that and standardize. We have a big group of therapists. We have 24 therapists for our five LINACs. So being intentional with the training is important, and that’s where you create the competency checkoff sheet. So before our therapists are signed off to be AlignRT users, they have to get checked off. The checkoff sheet will help you do the training in the same order for each person and maintain those same concepts of warm-up, ROI drawing, manipulating ROIs, taking the SSDs. All those are outlined in our competencies sheet.

After you have the competencies sheet developed, I recommend doing an annual in-service. Each year we do it just to refresh with every therapist the skills or if there’s any updates or any workflow changes. Just the yearly, “Hey, this is what we do. Just remember importing all the things is really important.” So my key tip for that is start with the super users, train intentionally, and revisit the basics regularly.

All right. Next, it comes to communicating and educating your patients. So one thing we’ve learned pretty quickly was that patient communication is just as important as the technology. Once your patient understands why you’re doing it, they’re more comfortable and they will perform better. That means if they understand that they’re uncovered, they have to lay still, there’s a camera watching them, they have that reassurance, that comfort there, even though they’re in a very vulnerable spot.

So it’s very important to start with sim. You want to communicate to them that they’ll be uncovered, that we have to leave the site we’re treating exposed. They’re not always comfortable with that at first, but if you explain why, there’s a camera watching you, it’s monitoring your movement, it turns the machine off, that helps. Use the same language in sim as you do on treatment. That way, they don’t get confused when they come for their verification sim or throughout. So if you’re telling them to take in a deep breath and hold, use that same terminology when you get to treatment. So it’s not like, “Just take in a breath,” or, “Hold your breath.” If you keep it consistent, the patient knows what to expect.

So knowing that they’re going to be uncovered is really important, especially when you get to the pelvis patients. We usually fold a towel, keep their private area covered, but then expose the legs. They get a little nervous at first, but if you tell them, “I just need to see your thighs and the outside of your legs,” they’re way more compliant with it, and they start to joke with you towards the end of fraction 35. They’re like, “I know I’ve got to spread my legs open, do all this thing.” And they just become more comfortable with it, and they actually start to line up faster. As they get used to it, they’ll just get down. They’ll just know to pull down their pants or take their shirt off, lay down. It’s very limited manipulation from there.

Another thing is you want them to hold still because if they go out of tolerance, you might have to re-image and all those. So reminding them that they have to hold still, that the cameras are watching them, and that, again, they’ll perform better, they’ll lay still if they know that they have to hold still, and that helps them know that they’re getting a better treatment and that we’re hitting the spot we’re supposed to hit. My key tip is patient communication is just as important as the technology, and having that empathy for the patient really plays a big role. If you acknowledge that they’re uncovered, that they feel vulnerable, they’re uncomfortable, if you just keep reassuring them along the way, that just will help with the SGRT using daily in your treatment. Just empathize with them, communicate with them, educate them.

As we kind of briefly already touched on, and you’ve seen this week in the other presentations, to roll out to your therapist in a phased approach. So phase one would be you still use your tattoos if you’re not ready to go tattoo-less. Align to your tattoos, turn on SGRT to use for your iso shift, manipulate your deltas, step out, perform your facility’s imaging, then just leave it on for monitoring throughout the treatment. That just gets them used to reading the screen, doing the movements, the shifts, and then once you get good at that, and you trust it a little bit more that the tattoos and the SGRT do the same thing, you can move into going straight to phase two, which would be just turning on SGRT. You can still have the tattoos if you want them, but they’re just there for backup. Turn on SGRT, get them in the green, and then do your imaging like you would, and just leave it on for treatment.

In our picture here, that’s our coworker, Matt. He was a great patient dummy for us. The postural video will be a game changer in your clinic. Definitely advocate to get that because—and that’s another way to sell it to your therapist, that it’s a great tool to use because you can get their arms in the right spot. You can get them exactly where they need to go. And then it also helps you kind of figure that you don’t need the tattoos as much because you have that contour from CT sim.

In our department, we don’t image our breasts daily. We just do the standard every five fractions. So after Vsim day in our department, day two, we take a pre-port tangent, get the doctor to approve it before we start treating to confirm any shift we made from vision was captured correctly on our surface, and that’s what we’re going to continue to use throughout the treatment. So that’s just our little thing. It’s not really a key tip, but each facility can figure out what they want to do best, but we just want to confirm that the reference shifts are still good from day one to day two. So a key tip here would be the SGRT isn’t replacing your judgment, it’s just additional information. Use it that way, and then you’ll see that your treatments get more efficient and more effective.

Sarah kind of touched on DIBH. When it comes to DIBH, it’s important to remember that it’s kind of a coach skill, not just a button you push. So that’s where it comes into talking to your patient in SIM, using the same terminology when you tell them to take in a breath. If you want them to take it in through their nose and tell their chest to rise up. We always tell ours not to arch their back, but you want to maintain that consistency when you get to the treatment machine as well. So for our DIBH, we turn on the SGRT, align to a free breathing surface first, get it all in the green, then we flip over to the DIBH. We have the patient take in their breath, and then their vertical is controlled with their breath. So once the vertical gets to the green with their breath, you can manipulate the table, lounge, lat, yaw, roll, pitch, and then you tell them to breathe. So that way you know that they have the same breath that they had in CT SIM. So a key tip there is repeatability comes from coaching and is not perfection, but aim for a breath hold that’s comfortable and consistent. Some patients start to freak out, and they take the deepest breath that they’ve ever taken, and they can’t make that happen again. So in SIM, do a couple practices, have them take a comfortable deep breath, and then have them proceed from there.

Once you get good at the breast chest area to start with, then you can go to any site. Do your pelvis, the frog leg pelvis, a brain faceless mask kind of thing, and then when you feel comfortable with that, you can go to your VMAT TBI, where you have multiple isos all connecting, and then you can just expand from there. Elbows, arms. We’ve done feet. You can just use it on anything.

 

 

 

*This transcript has been AI-generated. Contact us at secretary@sgrt.org if there are any issues.