This document discusses quality assurance requirements and resources for clinical radiotherapy. It outlines the philosophy of radiotherapy quality assurance as improving clinical practice quality, promoting consistency, ensuring accuracy, and validating clinical trial results. It then describes the integrated planning and delivery process and sources of errors. The document provides detailed guidelines for quality assurance procedures during pre-planning, immobilization, simulation/CT, volume determination, treatment planning evaluation, treatment verification and delivery, follow-up, and the importance of audits for quality assurance.
2. PHILOSOPHY OF RADIOTHERAPY QUALITY
ASSURANCE
Improve the quality of clinical practice minimizing the
risk of errors.
Promotion of consistency between centers
Ensuring accuracy and integrity of data
Validity of clinical trial results
Evaluation and correlation of radiotherapy parameters
with treatment outcome
6. PREPLANNING
To ensure the quality -
Assessment of the patient based on clinical/Radiological
Parameters- Intent of treatment should be clear
Full & detailed explanation of the procedure/precautions/Side-effects/
Dental prophylaxis
Follow a uniform departmental protocol and explain to the patient
Gyn-Bladder/ Rectal protocol
Lung- Still/ Normal breathing
Oral and or Iv contrast
Written informed Consent
Identification of correct patient by name, photo, RT no
Correct site and laterality
8. Get patient accustomed to the mouth bite or stent, if possible, prior to
making the mask to decrease the set-up errors
Temprature of the mask should be checked before placing on pts skin
Documentation of the fixed positions of all immobilisation devices
performed by RTT should be checked by clinician.
Any additional supports required for the procedure, such as knee rests
or shoulder retractors should be indexed to the couch
Mask selection
Low neck-5 point mask/3 point mask with shoulder retractor
9. Ensure that the patient’s airway is not compromised during the
procedure. This may necessitate enlarging the gap for the nasal and
mouth areas slightly.
For post-operative patients with tracheostomies in situ, care should
be taken to avoid airway obstruction. This will necessitate placing
petroleum-based gauze over the stoma, which will not obstruct
breathing, as well as making an appropriate sized gap in the material
to clear the tracheostomy site.
Any dentures, hearing aids, toupees, earrings and wallet etc should
be removed.
10. If possible, the patient should be provided with a gown, which can be
removed, as the procedure commences.
The patient should be positioned on the treatment couch, in the
prescribed treatment position as comfortably and reproducibly as
possible.
The sagittal laser should be used to ensure straightness, checking
that it bisects the nasal septum, sternal notch, xiphisternum and
symphysis pubis as much as is possible. This aids in the minimisation
of rotations.
All immobilisation devices must be indexed and fixed to the couch, to
minimise rotational and translational errors.
Neck rests should provide adequate support for the head and neck
and gaps should not be present underneath the head of the patient
nor at the top of the neck rest.
13. Identification of correct patient by name, ID and photo
Site and laterality
Marking of scars/Nodal regions
Contrast administration
Check the creatinine clearance
Screen for potential contrast anaphylaxis
Emergency trolley is prepared and fully stocked
Contrast is heated to body temperature 37 degree
Under supervision of Oncologist preferably by injector
14. Positioned / re-positioned accurately
Bolus placement
Correct scanning protocol/ localization protocol
Patient orientation and the orientation of the topogram
should be correctly entered at the CT console.
Appropriate axial slice thickness
To ensure sufficient anatomic detail for target and
organ at risk delineation.
To minimize the partial volume effect
For adequate anatomic details on DRRs from the
TPS for treatment verification procedures.
15. The dose length product , number of axial slices and scan
length should be documented in the patient chart.
Export the data to TPS/ virtual simulation correctly.
If contrast has been administered, the departmental
protocol in relation to observation should be adhered to
prior to the patient leaving the department.
17. Fusion uncertainties
GTV- Physician training for interpretation of imaging
/Help of radiologist or nuclear medicine/ correct window
selection/HU setting
CTV- follow std guidelines/peer review/uniform
department protocol/educational courses by
ASTRO,ESTRO
PTV- Institutional data for individual site to quantify their
own population- based errors and regular audits
Peer review/Shadowing experience person
23. PLAN EVALUATION TOOL: DVH
• A. Quantitative analysis of
DVH
• Hot spots/cold spots
• ? Location of hot/cold spots
• B. Examine homogeneity:
HI/CI
• C. Dose to OARs
• D. RVR (Remaining volume
at risk)
• E. Comparison of different
plans
27. 1st day set up should be monitored by Radiation
Oncologist regarding patient positioning and
immobilization.
Mask too loose / too tight- evaluate
Patient weight should be monitored weekly
If significant weight loss or gain----Re-plan
30. MATCH STRUCTURES FOR IMAGE VERIFICATION
Bony match structures/regions of interest (ROIs) for image
verification should be a surrogate for the target.
Depending on the tumour location, may include nasal septum,
vertebral bodies and processes, maxilla, angle of mandible,
base of skull, head of clavicle.
It may be useful to define primary and secondary match
structures at planning for use during image verification.
32. Primary match structures
Structures whose anatomy are in close proximity to the
target ,most useful for position comparison and, for 3D
volumetric imaging using CBCT, will determine the
position of the clipbox.
Secondary match structures
Structures whose presence are useful for guidance
purposes only.
37. Weekly monitoring of acute radiation reactions
Standard protocol- RTOG/CTCAE
Out of field reactions??
Sometimes exit beam of IMRT/ wrong side
Dietary counseling/ Nutrition/Need of Ryle’s tube
Documentation of toxicities/ Supportive care
39. AUDIT TO IMPROVE THE QUALITY
Promotes learning by addressing the following (A method of self
evaluation)
What am I doing?
How am I doing it?
Why did I do it that way?
Can I do it better?
Audits allow a critical review of current information (being up to date)
Highlights the need for specific knowledge / information, acquisition of
new skills / development of existing ones
Improves communication skills and flexibility in attitudes with other
members of the same team
Improves patient safety and quality of care
40. THE AUDIT CYCLE
Identify the need for change:
e.g. a problem identified in daily
practice-something that could /
should have been done better. 3
basic areas:
Structure:
manpower/premises/facilites
Process: provision of care
Outcome: Results in patients
Set a criteria:
i.e. an item of care used to assess
quality
Needs a standard of reference
(invent one - minimum, ideal,
optimum)
Collect data:
What data?
How and in what form?
Who collects it?
Assess performance against
criteria / standards:
Identify an area of care below
predetermined levels—develop an
action plan
Implement recommendations:
And then re-audit