Keeping a Finger on the Pulse: The Potential of a Programmatic Advanced Practice Role

Abstract

Stereotactic Body Radiation Therapy (SBRT) is a treatment technique that makes possible the delivery of highly focused high dose radiation in a single or few fractions. The SBRT program at our institution has grown rapidly in both anatomic sites and patient numbers since 2008; treating over 900 patients last year to sites including lung, liver, spine, prostate, kidney, pancreas, head and neck and miscellaneous oligometastases. Due to the rapid expansion and the highly technical nature of the program, a clinical specialist radiation therapy (CSRT) role was introduced in 2012 to ensure the highest quality patient care and efficient use of resources. In this role, the CSRT liaises with all disciplines within the radiation oncology program (radiation oncologists, medical physicists, radiation therapists and nurses) and across nearly all primary disease site groups. The responsibilities of the role include direct patient care through new patient, on treatment and follow up visits as well as programmatic leadership via the oversight of protocol standardization, development of new techniques and departmental education. A wide breadth of knowledge is required in this role and participation in patient care across all anatomic sites offers a unique and comprehensive perspective. A key responsibility of the CSRT is to manage and participate in peer review of all SBRT cases. The majority of peer review for SBRT cases is conducted via multi-disciplinary rounds led by the CSRT, who maintains detailed records of identified issues and recommendations. In additional to ensuring the highest quality of care for the patients, the data acquired from SBRT peer review has led to SBRT protocol standardization, process improvements and technique efficiencies. In 2017, 723 SBRT cases were peer reviewed in the multi-disciplinary setting led by the CSRT and 22 of these cases required follow up based on issues identified after peer review. Thirty-one out of 723 cases were completed outside of scheduled rounds at review initiated by the CSRT to ensure completion before more than half of the treatment was delivered. Inappropriate or missing contours was a common theme in cases requiring follow up and this lead to the standardization of chest wall, renal cortex and renal hilum contours across all sites. A trend in dose reduction in liver SBRT was observed and subsequently, a breath-hold technique was implemented in an attempt to reduce treatment volumes and facilitate the delivery of higher doses. Inconsistent dose constraints for abdominal organs were also identified and a task force to harmonize these across anatomical sites was initiated. With involvement in all anatomic sites, a programmatic advanced practice role in SBRT offers a unique perspective that ensures continuity and consistency across all anatomic sites. Continuous evaluation of treatment protocols and outcomes is imperative for the identification of opportunities for improvement across all sites.