Clinical Specialist Radiation Therapist Research Articles

How to Navigate During a Cyberattack - Palliative Clinical Specialist Radiation Therapist Role in Manual Delivery of Palliative Patients

How to Navigate During a Cyberattack - Palliative Clinical Specialist Radiation Therapist Role in Manual Delivery of Palliative Patients

Triage for palliative radiotherapy by clinical specialist radiation therapists: A scoping review.

Patients who could benefit from palliative radiotherapy (PRT) may be in different phases of the cancer journey: they may have minimal symptoms and preserved functional status, or could be near end of life, with multiple complex care needs. Efficient triage at PRT referral is crucial to match patients with an appropriate provider and care setting as quickly as possible. Many centres have a dedicated PRT clinic, for which triage occurs by a Palliative Clinical Specialist Radiation Therapist (PCSRT). We performedan English-language literature search of 15 databases, without date limits, based on the PICO framework. After independent screening of titles and abstracts by two authors, relevant full text papers were reviewed. Twenty studies (15 publications and five abstracts) and one government report met inclusion criteria. Studies were published over a 21-year period by investigators from four countries. By identifying bottlenecks, screening out inappropriate referrals, and assessing patients in advance of consult, PSCRT triage decreased wait times by approximately 50%, on average, compared to standard pathways (range 30-82%). Increasing efficiency by pre-booking and coordinating appointments increases patient volumes and optimizes use of resources. A triage PCSRT serving a navigator role improves continuity of care, and in decreasing the number of handoffs, safety as well. Shifting triage to a PCSRT allows multidisciplinary team members to work to their maximum scope. In one clinic, after incorporation of PCSRT triage, use of on-call services decreased, as more patients were seen during daytime appointments, contributing to cost-savings.

The palliative clinical specialist radiation therapist: A CAMRT White Paper

Palliative radiation therapy (pRT) is an effective tool for people with incurable cancer, in the treatment of many cancer-related symptoms such as pain, bleeding and dyspnea. As utilization rates for palliative radiation therapy increase, the demands on the healthcare system continue to grow. Radiation Therapists with advanced knowledge, skills and judgements began demonstrating their ability to practice autonomously in 2004, with the development of the Clinical Specialist Radiation Therapist (CSRT) role. Since this time, CSRTs with a specific focus in pRT (pCSRT) have been increasing in both numbers as well as their positive effects on the cancer care system. Integrating a pCSRT into the existing pRT system has resulted in increased access to and quality of pRT being delivered to palliative cancer patients. The benefits of the addition of pCSRTs to the cancer care system include increasing system capacity and increasing quality of care. This white paper provides information related to the improvements that can be realized in a RT program related to the care and treatment of its palliative patients by adding a pCSRT to the interprofessional healthcare team and suggest it as one of many strategies that can be undertaken to make improvements to access and quality of care.

A Canadian experience of palliative advanced practice radiation therapy TIPS: Training, implementation, practice and sustainability.

The concept of the Advanced Practice Radiation Therapist (APRT) was created in 2004, in response to pressures on the radiation treatment sector in Ontario. This led to development, piloting and integration of the Clinical Specialist Radiation Therapist (CSRT) into Ontario’s cancer care framework. A national certification process, competency profile and protected title of APRT(T) were established in 2017, under the Canadian Association of Medical Radiation Technologists (CAMRT), in collaboration with Cancer Care Ontario/Ontario Health. This report describes the approach to development, validation and measuring impact of the CSRT role in Ontario, specifically in palliative care (pCSRT). It also presents information to assist jurisdictions interested in developing a pCSRT position, describing competency development, assessment, and assumption of practice, and providing some keys to success. This is foundational for consistent expansion of the pCSRT role to other regions to continue to increase system capacity while improving the quality of cancer care.

The emerging role of radiation therapists in the contouring of organs at risk in radiotherapy: analysis of inter-observer variability with radiation oncologists for the chest and upper abdomen.

AimsTo compare the contouring of organs at risk (OAR) between a clinical specialist radiation therapist (CSRT) and radiation oncologists (ROs) with different levels of expertise (senior–SRO, junior–JRO, fellow–FRO).MethodsOn ten planning computed tomography (CT) image sets of patients undergoing breast radiotherapy (RT), the observers independently contoured the contralateral breast, heart, left anterior descending artery (LAD), oesophagus, kidney, liver, spinal cord, stomach and trachea. The CSRT was instructed by the JRO e SRO. The inter-observer variability of contoured volumes was measured using the Dice similarity coefficient (DSC) (threshold of ≥ 0.7 for good concordance) and the centre of mass distance (CMD). The analysis of variance (ANOVA) was performed and a p-value < 0.01 was considered statistically significant.ResultsGood overlaps (DSC > 0.7) were obtained for all OARs, except for LAD (DSC = 0.34 ± 0.17, mean ± standard deviation) and oesophagus (DSC = 0.66 ± 0.06, mean ± SD). The mean CMD < 1 cm was achieved for all the OARs, but spinal cord (CMD = 1.22 cm). By pairing the observers, mean DSC > 0.7 and mean CMD < 1 cm were achieved in all cases. The best overlaps were seen for the pairs JRO-CSRT(DSC = 0.82; CMD = 0.49 cm) and SRO-JRO (DSC = 0.80; CMD = 0.51 cm).ConclusionsOverall, good concordance was found for all the observers. Despite the short training in contouring, CSRT obtained good concordance with his tutor (JRO). Great variability was seen in contouring the LAD, due to its difficult visualization and identification of CT scans without contrast.

Clinical Specialist Radiation Therapist in Palliative Radiation Therapy: Report of an Orientation, Training, and Support Program

IntroductionA clinical specialist radiation therapist (CSRT) position in palliative radiation therapy (RT) was created at our institution. Herein, we report the details of the CSRT's orientation, training, and support program. MethodsWe performed an audit and needs assessment of palliative RT services at our centre. This identified opportunities for improvement that could be facilitated by the CSRT. We defined the CSRT job description including priority responsibilities: (1) optimizing palliative RT services for outpatients and developing a rapid access palliative RT program, (2) optimizing palliative RT services for inpatients at our institution, (3) improving links to community physicians and hospitals caring for patients with advanced cancers. We formed a core resource team to provide ongoing support and to design and implement the orientation and training program. The program involved training in clerical and administrative systems as well as treatment planning and physics training relevant to palliative RT. Clinical placements at several hospitals were arranged in both inpatient and outpatient settings. The CSRT worked with radiation and medical oncologists, palliative care specialists, nurse practitioners, hospitalists, and social workers. ResultsThrough clinical placements and self-directed learning, the CSRT gained knowledge and competencies in patient care coordination, history taking and physical examination, clinical oncology practice including the evidence-based use of palliative RT and symptom control measures, treatment planning, communication, patient advocacy, and advance care planning. We provided practice resources including office space and a planning station, educational opportunities including workshops in palliative and psychosocial care, and research opportunities including methodologic and research ethics training. DiscussionTo our knowledge, this is the first detailed report of its kind for an advanced practice radiation therapy role. We hope our report will inform the design and implementation of programs elsewhere to help prepare individuals for similar roles in palliative RT. ConclusionThe CSRT in palliative RT at our institution underwent a comprehensive orientation and training program. Institutions with similar CSRT positions are encouraged to report the details of their own programs.

Improving the Quality of Patient Data Capture in Breast Radiotherapy Peer-Review

The importance of multidisciplinary peer-review rounds is widely recognized. Peer-review rounds ensure the quality and safety of individual radiation therapy (RT) treatment plans. At our institution, breast cancer RT peer-review rounds are conducted weekly over 1-hour session, with attendance from radiation oncology, therapy, physics staff and trainees. All newly diagnosed breast cancer patients undergoing radical RT are scheduled for peer-review approximately 1 week prior to their treatment start date. One challenge in conducting peer-review for a large disease site is the ability to systematically review all patients within the limited time constraints. Our objective is to develop a comprehensive patient list with essential patient, tumour, and treatment factors for peer-review and to evaluate its feasibility. A standardized list of patient information essential for peer-review were identified by the site group. The core patient clinicopathologic parameters were entered into the RT Electronic Medical Record (RT-EMR) by the clinician at the time of radiotherapy prescription. Patient information included: age, clinical/pathological stage, surgery type, chemotherapy sequence, tumour size, histology, tumour grade, lympho-vascular invasion, margin status, nodal positivity, ER, PR, and HER2 status, and a comment section. Aside from tumour size, margins, nodal status and comments, all data inputs used dropdown menus, which ensured data consistency and reduced free-text entries. Standard RT prescription selections were templated in accordance with our institutional practice guidelines to facilitate uniformity. All patient parameters extracted from the RT-EMR were transferred to a spreadsheet and evaluated for completeness by a Clinical Specialist Radiation Therapist (CSRT) prior to rounds. For patients with insufficient data for peer-review, missing data were retrieved manually and entered by the CSRT through review of dictated clinic notes. The rate of completion and time required to retrieve missing information were captured following the implementation of the automated data extraction process. RT-EMR data were collected over 40 weeks between April 2015-April 2016. The average patient data completion during the first month of implementation was 64% (SD10) and increased significantly over time to 86% (SD4) in the final month (p<0.001). The time required to ensure data completion was inversely correlated with the overall data completion rate (Pearson r=-0.702;p<0.001). An average of 18 (SD4) patients were peer-reviewed weekly in rounds. The standardization of RT prescription selection and clinicopathologic data streamlined the peer-review process in rounds and significantly decreased preparatory time; mean reduction from 2hr:40mins (first month) to 1hr:15mins in the final month (p=0.005). The standardization and consistent entry of patient’s clinical-pathology data decreased time required for review of transcribed notes for missing patient information. The use of a comprehensive peer-review list is feasible and supports peer-review of all radical breast RT plans, even in the absence of the attending radiation oncologist. Direct entry of patient information at the time of RT decision-making enhances efficiency and allows prospective data capture, reduction of human resources, and avoidance of manually reviewing transcribed clinical notes.

Identifying a Niche: Development of the Orthopedic Radiation Oncology Clinic

The Orthopedic Radiation Oncology Clinic (OROC) was recently developed to identify patients at risk of pathologic fracture of weight bearing long bones, to provide education to patients and staff regarding fracture risk and weight bearing restrictions, to provide rapid access for radiation therapy services, to provide timely access for orthopedic surgical interventions and to provide follow-up services for patients with Metastatic Bone Disease (MBD). At our institution, prior to the development of the OROC clinic, on-call orthopedic evaluation was utilized to determine a patient’s pending fracture risk as identified in the radiographic report. The use of orthotic devices was limited to spinal braces and Radiation Oncology follow-up care and rehabilitation services was minimal and inconsistent. As orthopedic surgical intervention reduces pain, preserves function, minimizes fracture risk and improves quality of life, the OROC clinic was developed as an interdisciplinary assessment for patients with MBD to the appendicular skeleton. It is facilitated by an Orthopedic Oncology Surgeon, a Radiation Oncologist and a Clinical Specialist Radiation Therapist (CSRT) and operates weekly. The CSRT is the liaison and primary contact for referring physicians and specialists. Within the OROC clinic, the responsibilities of the CSRT are to triage referrals, identify diagnostic imaging required for patient fracture risk assessment, coordinate rapid access radiation therapy, patient navigation including assessment and education. From April to July 2018, a retrospective quality assurance chart review from the OROC clinic was completed. Information regarding fracture risk category and interventions including referrals, orthotic devices and patient education material were collected. 29 patient consultations and 9 follow-up visits occurred. 11/29 (38%) patients were identified as high risk of pathologic fracture and received restricted weight bearing instructions. 5/29 (17%) were offered prophylactic orthopedic intervention. 20/29 (69%) received palliative radiation therapy. 4/29 (14%) were referred for prosthetic and orthotic devices and 3/29 (10%) were referred for physiotherapy services. Preliminary data supports the interdisciplinary OROC objective of providing rapid access to centralized coordinated care in an effort to improve patient education, time to treatment, provide follow-up and rehabilitation services. Future partnership with a community based rehabilitation program will ensure consistency of post treatment care for patients with skeletal related events of the appendicular skeleton. Further research is required to measure outcomes in addition to establishing best practices for patients with MBD of the appendicular skeleton.

Defining advanced practice in radiation therapy: A feasibility assessment of a new healthcare provider role in Ontario, Canada

IntroductionThis study assesses the feasibility of a new role for radiation therapists in Ontario, Canada, called the Advanced Practice Radiation Therapist (APRT), which would address health service pressures and improve patients’ access to care. MethodsA literature search and expert consensus were used to define advanced practice. A standardized template was used to record each APRTs activities/competencies, along with the requisite knowledge, skills and judgment required to perform these competencies. A thematic analysis of the lists was undertaken to develop a single competency profile. Seven APRTs were deployed at four cancer centres to gather contextual information on the development and integration of the new role. ResultsThe definition of AP consists of seven key traits and includes a framework identifying stages of practice from entry-level practitioner through expert to advanced practitioner. The competency profile consists of clinical, technical and professional domains which further define the scope of practice and shepherd the role through stages of implementation. Role testing showed support for the role and demonstrated that APRTs can deliver specialized services, perform delegated tasks and their work can lead to program efficiencies and new services. The new role may also lead to improved radiation therapist recruitment rates and work satisfaction. ConclusionsThis feasibility assessment served as the foundation for the future long-term implementation of the Clinical Specialist Radiation Therapist (CSRT) Project. As of 2018, there were 24 CSRTs in Ontario. The APRT role is a natural progression for a readying profession which can play a transformative role in addressing health human resource shortages.

Outcome Measurement: Developing Standardized Advanced Practice Workload Measurement Tools Across the Province With Workload Codes

The Clinical Specialist Radiation Therapist (CSRT) pilot project ran in Ontario from 2007-2016. During the period, individual and summative reports were generated to document the impact of CSRTs in the health care system. As the pilot project concluded and CSRT positions sustained, the CSRT Community of Practice (CoP) group recognized the need to continuously capture workloads of CSRTs across the province to provide data for senior management to assess impact and value of CSRTs in the health system. Therefore, the CSRT CoP created a working group to develop new workload codes to capture advanced practice workload. The workgroup sent out request to all CSRTs in the province to collect all the new codes the CSRT deemed necessary to capture their advanced practice activities. The group then reviewed all the new codes, grouped similar requests and compared to the existing provincial workload codes for duplication and differentiation to generate a master list. The master list is then mapped against the CSRT core competence profile to classify different advanced practice activities into different categories. At the first phase of code development, a list of new codes reflecting the CSRT advanced practice core competency and common to most CSRTs across the province is developed. The new codes will be able to standardize the workload measurement of CSRTs in different cancer centers. The standardized codes also allow provincial leadership to analyze the impact and contribution of CSRTs in the health care system and make informed decisions on future strategic plans. The CSRT CoP developed standardized workload codes to measure advanced practice activities and will obtain approval to use the codes from cancer centers in the province. The CSRT CoP will continue to assess the use of the codes and to refine its completeness. As the CSRT positions evolve and new positions developed, the CoP will adapt and/or introduce new codes as needed.

Prostate Delineation for LDR Prostate Brachytherapy: Concordance Study Between Clinical Specialist Radiation Therapist and Radiation Oncologist

Permanent seed brachytherapy for prostate cancer is a transperineal technique where radioactive sources are either permanently implanted into the prostate. Recently, funding guidelines for permanent seed implants as a treatment option for men with prostate cancer have changed in Ontario with funding now available for men with low and intermediate risk disease. As a result, the number of permanent seed prostate brachytherapy treatments has increased. Given radiation oncologist (RO) time constraints, we propose exploring the delegation of target delineation of the prostate for permanent seed treatment planning to an advanced practice clinical specialist radiation therapist (CSRT) in brachytherapy. The primary aim of this study is to determine the feasibility of CTV target delineation by the brachytherapy CSRT by testing the concordance between CSRT delineation and the gold standard. Between February 2013 and May 2013, 23 TRUS volume studies were completed on prostate cancer patients considering LDR permanent seed brachytherapy treatment. Acquired ultrasound images were imported into VariSeed treatment planning system (Varian Medical System Inc. Palo Alto, CA) for contouring. Prostate contours were completed independently by one CSRT and one Radiation Oncologist (RO, gold standard). All contours were then exported to MiMVISTA (MIM software Inc. Cleveland, OH) for analysis. Total prostate volume, union and intersection volumes were determined. To assess similarity of prostate volumes between the CSRT and the RO, the DICE index was used. The index is a scale from zero to one with an index of zero indicating no overlap of contours and an index of one representing complete unity or overlap of contours. The mean prostate volume for all 23 patients was 34.75cc vs. 37.33cc between the CSRT and the gold standard respectively. The mean DICE index value was 0.92 (range 0.82-0.95). The areas of greatest variability occurred at the base and apex of the prostate. This feasibility study found that there is high concordance between prostate delineation performed by an advanced practice CSRT and an RO. These early findings provide evidence that CSRTs are capable of accurately contouring prostate volumes on TRUS volume studies. Future work will describe the variability between all ROs performing prostate brachytherapy and the CSRT.

Are We on Track? The Role of Clinical Specialist Radiation Therapist (CSRT) in Developing the Dose Tracking and Adaptive Radiotherapy Program

Delivering precision radiation medicine is one of the strategic priorities at our institution. This is achieved by individualizing the radiation treatment plan based on the patient’s characteristic and/or adapting in order to respond to changes observed during the treatment course. Three Clinical Specialist Radiation Therapist (CSRT) were recruited to develop this process for clinical implementation. Competency on image interpretation, contouring, image registration and dosimetric image assessment were developed through weekly meeting with a multidisciplinary team. Based on the clinical expertise on the treatment technique and workflow, each of the 3 CSRTs was assigned to identify site-specific requirements by simulating the dose tracking process for the head and neck, lung and prostate treatment sites. The CSRTs collaborated with radiation Physicists in validating the tools for the dose tracking process and developed site specific workflows. With the wealth of clinical experience, CSRTs were able to identify risk and limiting factors, and provide valuable feedback to help improve the efficiency of the automating the dose tracking process. In addition, various research activities were conducted to evaluate the feasibility and efficacy of adaptive radiotherapy. The CSRTs will continue on developing the dose tracking process for other disease sites and to establish criteria or threshold for adaptive radiotherapy. Training will be provided to equip other radiation therapists to be competent in this process.

Leading Practice: Implementation of an Innovative Approach to Rapid Breast Radiotherapy

Whole breast radiotherapy (RT) is a standard management approach in early-stage breast cancer post-lumpectomy. Typically, the multi-step planning process requires wait-times varying from a few days to weeks. At our institution, the Clinical Specialist Radiation Therapist (CSRT) role has arisen as an integral part of an inter-professional team. The breast CSRT functions within the RT on-treatment reviews to assess and manage patient side effects and completes target volume delineation in select early-stage patients. The CSRT role development and validation occurred in parallel to the technological development of automated treatment planning software, which reduces multi-levels of manual planning. The incorporation of new models of care and technological innovation enable the development of a rapid breast RT process. The QuickStart program was developed with the goal to shorten wait-times for whole breast RT. Patients treated through this program have CT simulation, treatment planning and delivery of the first treatment fraction within 24 hours. The streamlined process is led by the advanced practice CSRT, who is responsible for all essential activities required to expedite the planning process, including upfront coordination of CT and treatment times, target delineation, and ongoing communication with the team and patient. The CSRT’s involvement in target delineation for the oncologist’s review and approval allows for increased workload flexibility of the radiation oncologists, enabling them to dedicate time to other complex medical issues and the provision of additional patient care activities. This furthers more efficient and cost-effective models of care. Initial results from a clinical study showed that women treated through QuickStart process received their first treatment 11 days in advance of similar patients treated through the standard process. Departmental quality control checks performed prior to the initiation of RT treatment did not detect any clinical or technical deficiencies in any of the plans. Independent peer-review of each plan in Quality Assurance rounds demonstrated 100% compliance with the departmental protocol. The QuickStart process effectively shortened the wait interval between patient consultation to the initiation of RT treatment and allowed patients to be treated well before the 14-day wait-time standards endorsed by Cancer Care Ontario. Since its inception, the program continues to be expanded to accommodate more patients. To date, more than 340 patients have been treated through this streamlined process. The QuickStart program helps to ensure patients have timely access to high quality care while enabling providers to: collaborate, further best practices, maintain a manageable workload and optimize the use of healthcare resources in a sustainable manner. By aligning the roles within a multidisciplinary team and leveraging technology, patient wait times can be reduced considerably. This innovative model of care offers breast cancer patients the same high quality and effective RT without a delay. Currently, the CSRT is training treatment planners to contour the post-operative cavity to further increase access to this process. Identification of the organizational enablers required for the Breast QuickStart process will enable the development of new models of care within other multi-disciplinary radiation oncology disease sites.

Co-ordinating Care for Prostate Brachytherapy Patients: Piloting a New Role for the Brachytherapy Clinical Specialist Radiation Therapist (CSRT)

Care coordination is defined as efficient and effective use of healthcare resources to improve the quality of care delivered to patients and their outcomes (1, 2). Given the complex nature of preparing for brachytherapy treatments for prostate cancer patients, a coordinator role was piloted to understand the potential impact the role could have for the patient and the system. Between November 2016 and November 2017, a role was piloted to aid in coordinating the prostate cancer patients’ movement through the system, be a primary contact for patient at first referral, provide a robust connection point throughout the patient journey with brachytherapy, and ensure the patient is clear about expectations, requirements and scheduling. Target patient population were those seen at a peripheral clinic or who received a virtual consultation via Ontario Telemedicine Network (OTN) with one Radiation Oncologist (RO). The Brachytherapy CSRT ensured proper work up for the patient, coordinated appointments, made appropriate referrals when necessary, provided patient education regarding upcoming brachytherapy appointment. This pre-op work was coordinated virtually. Workload was captured for each patient via MOSAIQ. Initial impact was assessed through a documentation audit. Frequency of patient preparedness, completion of anaesthesia questionnaire, and completion of pre-op bloodwork and ecg are reported for all prostate patients treated during the time period. A total of 32 patients were treated with brachytherapy of which 24 patients were coordinated by the CSRT and 7 patients were not. For patients not coordinated by the CSRT, two patients expressed not being prepared for the procedure and required further information, 1 patient did not have the anaesthetic questionnaire completed, 8 patients did not have pre-op bloodwork and ecg completed. For patients coordinated by the CSRT, 1 patient required further clarification about preparation for brachytherapy treatment; for all other work up was complete. The Brachytherapy CSRT coordinator role appears to move the patient through the system more seamlessly. Further investigation is required to understand the full impact this role could have on the patient and the system.

Sustainability is Success: Using Evaluation to Set the Course for Clinical Specialist Radiation Therapist (CSRT) Community of Practice

Sustainability is Success: Using Evaluation to Set the Course for Clinical Specialist Radiation Therapist (CSRT) Community of Practice

The Speedy CTV: Development of an Adaptable CTV Mesh to Decrease Contouring Time for Palliative Spine Patients Requiring Same-day-simulation-and-treatment

Same-day-simulation-and-treatment can be utilized to provide radiotherapy treatment for palliative patients requiring urgent symptom management. Significant coordination is needed to complete tasks required for safe, effective delivery of radiotherapy in a timely manner, which can be resource-intensive. At our institution, many palliative patients receiving same-day-simulation-and-treatment are treated to the spine. Depending on the length of spine involved, contouring times can vary. An adaptable CTV mesh was developed to decrease contouring times and the overall length of same-day-simulation-and-treatment. DICOM coordinates were obtained from 58 patients who underwent palliative radiotherapy to the spine delivered using volumetric modulated arc therapy (VMAT). Coordinates corresponded to vertebral levels of T6/T7, T12/L1 and L5/S1. Using MatLab™, CTV contours were overlaid and aligned at the three specified vertebral levels, graphed and averaged to create a three-dimensional ‘average CTV mesh’ of the lumbosacral spine. This mesh was imported into the treatment planning system, where it can be loaded onto patient data sets as an organ model. It can also be adapted using various contouring tools in the sagittal, transverse and coronal planes. Ten cases were contoured by a Palliative Clinical Specialist Radiation Therapist using both the standard workflow and the average CTV mesh. Contouring times were recorded using both tools. The ‘average CTV mesh’ of the lumbosacral spine was successfully loaded onto all ten patient datasets. Contouring times varied, and were equivalent or longer than manual contouring times. It was noted that this was likely due to a learning curve using the ‘average CTV mesh’ tool. Additionally, the tool can be modified further with bone-specific settings to better conform the CTV to the spine. In conclusion, the ‘average CTV mesh’ tool has the potential to decrease contouring times. The addition of bone-specific settings and further user training will assist in improving this clinical tool.

Implementation of the Palliative Clinical Specialist Radiation Therapist Improves Access to Care for Patients Referred for Palliative Radiation Therapy

Implementation of the Palliative Clinical Specialist Radiation Therapist Improves Access to Care for Patients Referred for Palliative Radiation Therapy

Impacting on the Patient and the System: The Role of Clinical Specialist Radiation Therapist in a Multidisciplinary Skin Cancer Clinic

Impacting on the Patient and the System: The Role of Clinical Specialist Radiation Therapist in a Multidisciplinary Skin Cancer Clinic

The Clinical Specialist Radiation Therapist (CSRT): A case study exploring the effectiveness of a new advanced practice role in Canada.

IntroductionThe Clinical Specialist Radiation Therapist (CSRT), is a new advanced practice (AP) role for radiation therapists (RTTs). Following training, education and evaluation, the CSRT performs specific duties in autonomous ways, making advanced clinical decisions in their area of specialization. This case study examines the CSRT's impact on quantity (i.e., increasing capacity), improving quality and stimulating research and innovation.MethodsBetween 2007 and 2016, 23 CSRTs worked in 10 cancer centres in various AP position. A standardised metrics package, focusing on wait‐times, patient volumes, patient throughput, time‐savings, quality initiatives, satisfaction, research and innovation was developed and used to collect qualitative and quantitative data. Data were self‐reported by the CSRTs but electronic databases, pre/post‐studies, surveys and interviews were also used.ResultsQuantity projects (n = 76) related to patient volumes, wait‐times, patient throughput and time‐savings increased capacity and allowed more patients to enter the system. The presence of a CSRT allowed, on average, 13 additional patients (either new or re‐treated) to be seen, at their respective cancer centre, per month. An average of 1.4 yearly quality improvement initiatives were led by each CSRT, which contributed to improvements in quality of care and satisfaction. CSRTs demonstrated a high level of involvement in research, innovation and knowledge translation activities, either as leaders or part of interprofessional teams.ConclusionCSRTs positively impact quantity (capacity of the system), quality, research and innovation. Future efforts include permanent and sustainable team integration, practice standards, formal and comprehensive educational preparation, and approaches to consistent, valid assessment of AP in radiation therapy.

Leveraging Advanced Practice: Building Capacity and Maximizing Impact

The Stereotactic Body Radiation Therapy (SBRT) program at our institution has rapidly grown in both anatomic sites and patient numbers since 2008; treating over 700 patients last year to sites including lung, liver, spine, prostate, kidney, pancreas, head and neck , bone and nodes. With such a rapidly expanding program, a clinical specialist radiation therapist (CSRT) position was created in 2012 to ensure optimal, consistent care across the program. Since inception, the role has demonstrated significant impact in terms of time savings for physicians and improved quality of care for patients. The next logical step was to translate the expertise of the CSRT into programmatic efficiencies. An initial area of focus for the position was to have the CSRT assume responsibility of approval of day 1 cone beam computed tomography (CBCT) registrations in place of the radiation oncologist (RO). The CSRT attained competence through a combination of didactic and practical instruction. Concordance between the CSRT and RO with respect to CBCT registration assessment was established. As the department's experience in certain sites of SBRT matured, specific clinical scenarios were identified where, with appropriate training, treatment therapists could independently review day 1 CBCT images for SBRT treatments. The CSRT implemented a therapist led day 1 CBCT registration review policy and facilitated staff education through creation and delivery of an instructional module. A follow up audit was performed to ensure maintenance of quality standards and to quantify departmental impact. Benefits: Greater autonomy for radiation therapists; Eliminated need for calling a third party for treatment and resultant delays; Freed up CSRT to focus on more complex tasks. Challenges: Maintaining continued clinical competence throughout department; Consistent adherence to new guidelines; Managing challenging cases within sites identified for therapist review. The progression of the CSRT in SBRT role highlights how advanced practice radiation therapy roles should evolve continuously. To maximize impact, it is necessary to be cognizant of the changing needs of the department and to align the role accordingly. This process demonstrated how advanced knowledge, skills and judgment of CSRTs can be leveraged for wider departmental benefit.