Download A review of the ACDS pilot: What was accomplished and why it worked

A review of the ACDS pilot:
What was accomplished and why it worked
Ivan Williams, Joerg Lehmann, Jessica Lye, John Kenny, Leon Dunn,
Duncan Butler, Andrew Alves, Andrew Cole, Tomas Kron.
Overview
The Australian Government launched the
Australian Clinical Dosimetry Service
(ACDS), a three year trial of an independent
dosimetric auditing service for Australia in
Feb 2011.
Tasks:
• Design a peer reviewed three level national dose audit program
• Recruit facilities across Australia to participate in a pilot program
• Implement program (with target numbers) and create data base
Building on existing expertise the program was to be unique in coverage,
national participation (voluntary and free service), audit design and final
review process.
2
Radiation Therapy in Australia
• 50,000+ Australians treated p.a.
• ~170 clinical linacs
• Increasing
• Demands – new facilities
• Workload – within facilities
• Complexity – technology and
outcomes
Special thanks to Dr Scott Crowe & google!
• Regional facilities, country facilities and some metropolitan facilities do
not have local support
• Professional demand for formal audit centre
ACDS: Structure
MOU
Department of
Health and Ageing
CAG
ARPANSA (CEO)
Formal
Responsibility
ACDS
Branch Head
Medical Radiation
Daily
administration
Information / Reporting:
DoHA : 3 months
CAG: 3 – 4 Months
ACPSEM, AIR, RANZCR
Auditors
Centres
ACDS Audit Levels
Diagnostic
Target
Treatment
Beam
Patient
Imaging Outlining Planning Calibration Setup
Level I
Level II
Level III
Level I:
Level II:
Level III:
Linac output under ref conditions
Treatment planning and delivery
End-to-End test
T Kron et al., IJROBP 52(2), 566–579, 2002
J Lehmann et al., Spectrum 19(10), 14-17, 2012
Treatment
Record
Delivery and Verify
Level I
• Passive dosimeter placed in standard clinical beam in
environment with well understood conditions
• External audit by mail
• Started with TLD (IAEA approach)
• Shift to OSLD following rigorous testing
(L Dunn et al, Radiation Measurements 51–52, 31–39, 2013)
6
Level II
-
Treatment planning and delivery
Onsite audit with planar detector in
rectilinear geometry
Synthetic CT sets
Prescribed treatment plans
Measurements at multiple depths
Level III
Humanoid thorax phantom goes through the complete chain of procedures a
patient experiences in Radiation Therapy.
Diagnostic
Imaging
3D Treatment
Planning
Patient
Setup
Treatment
Delivery
Record
and Verify
Level Ib – by consumer demand
• On-site measurement with ionisation chambers for photons and electrons
(IAEA TRS-398)
• Required in many European Nations
• Required by Australian Radiation
Oncology Practice Standards (cr 15.1.)
• Offered to facilities based on risk criteria
ACDS: Audit targets achieved!
Status at Dec 30th 2014 after three years of operation.
Audit
Level I
Level Ib
Level II
Level III
Status against
MoU
Complete
Outside MoU
Complete
Complete
Required by
MoU
103
54
22
Linacs
audited
149
28
63
52
Linacs in
progress
16
0
0
0
ACDS Results
# Audits
Audit
Type
Level I
Level Ib
Level II
Level III
# Unique Linacs
Pass
Optimal
Pass
Action
Level
Fail
Protocol
Violation
46
25
12
11
12
2
3
9
1
1
8
2
1
0
1
0
Pass
Optimal
Pass
Action
Level
Fail
Protocol
Violation
111
25
31
28
35
2
5
11
2
1
23
4
2
0
3
0
Note: This is a dose audit, not a clinical audit
Recommendations from the ACDS
The ACDS has made over 63 recommendations to 24 clinical
departments. These recommendations have led to
• clinical reviews of treated patients extending back over two
years;
• changes to clinical protocols to exclude radiation fields
which were not correctly modelled;
• replacement of a number of obsolete or unstable
measurement devices;
• changes in the internal QA and QC practices within clinics.
12
ACDS general recommendations
1. Ensure that the (your) barometer is calibrated (properly).
2. If your dosimetry equipment, (ionization chamber) is faulty
or out of date, replace it.
3. Try to head-off legacy issue w.r.t. physics staff and loss of
institutional knowledge (really really important)
4. Ensure that the facility staff commission new equipment. If
you need to hire outside physics staff, use them to perform the
routine clinical work. The local physics staff should (must?)
commission the new equipment.
13
Internal notes
• The ACDS needs to maintain clinical relevance & familiarity
 staff turnover and/or job sharing
 mix of clinical experience, physics expertise and computer
modelling skills
• The ACDS has a deep knowledge of dosimetry and could have a role
in Resident training and training workshops.
• Success due to collaborative ethos within the ACDS and with the
outside world.
Why was the ACDS a success?
Michigan Keystone I project as an example of a QI that worked in
the health space. Analysis from a social sciences perspective II:
1. Social (Isomorphic) Pressures
2. Networked community efforts
3. Re-framing dosimetry issues partly as a non-technical social
problem
4. Changing practice and culture at the ‘sharp end’ by using
interventions with different effects
5. Using data as a disciplinary force
6. Skilfully using ‘Hard Edges’
I.
II.
Provonost et al., An intervention to reduce catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26):2725, (2006).
Dixon-woods M, Bosk CL, Aveling EL et at., Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program. The Milbank Quarterly, 89(2), 167-205,
(2011).
Social Pressures
• Professional organisations publically engaged (driving) with the
service
• A large number of organisations immediately participated
• Senior staff from participating facilities made an explicit
commitment to perform work (audits) over a loose non-binding
timeframe.
• Keeping up with the Jones’
Networked community efforts
• Clinical Advisory Group providing feedback into the professional
bodies
• Engaging with professions through State and National conferences
• Publications
Dosimetry issues as social problem
A social problem: cannot be solved through a technical solution.
Requires a change in human action and behaviour - (culture?).
Changing practice and culture through intervention
Recommendations in most cases related to dosimetric discrepancies
Occasional formal written recommendation pertaining to obsolete or
unstable equipment was made.
Usually facilities launched their own investigations, corroborated the
ACDS findings and changed local protocols and/or sped up new
equipment commissioning.
Using data as a disciplinary force: I
• Lvl II Report details each plane measured
• 1500 points analysed per Lvl II audit
Using data as a disciplinary force: II
Lvl III Report details each point in each case measured
Case 2
Case 3
Case 4
2 3 4
5
Using data as a disciplinary force: III
I. Williams, J. Kenny, J. Lye, J. Lehmann, L. Dunn, T. Kron, "The Australian Clinical Dosimetry
Service: a commentary on the first 18 months," Australasian Physical & Engineering Science in
Medicine, 1-5 (2012).
II. Leon Dunn, Jessica Lye, John Kenny, Joerg Lehmann, Ivan Williams, Tomas Kron, Chris Oliver,
Duncan Butler, Tanya Kairn and Peter Johnston “Commissioning of optically stimulated
luminescence dosimeters for use in radiotherapy”, Radiation Measurements 51–52, 31–39
(2013)
III. Joerg Lehmann, John Kenny, Jessica Lye, Leon Dunn, Ivan Williams “Trust, but verify –
Accuracy of clinical commercial radiation treatment planning systems”, ICCR 2013, IOP, J.
Phys.: Conf. Ser. 489 012094 doi:10.1088/1742-6596/489/1/012094
IV. Joerg Lehmann, Leon Dunn, Jessica Lye, John Kenny, Andrew Alves, Andrew Cole, Tomas Kron,
and Ivan Williams “Angular dependence of the response of the nanoDot OSLD system for
measurements at depth in clinical megavoltage beams”, Med Phys 41(6), 2014
V. J. Lye, J. Kenny, J. Lehmann, L. Dunn, T. Kron, A. Alves, A. Cole, I. Williams, “A 2D ion chamber
array audit of wedged and asymmetric fields in an inhomogeneous lung phantom,” Med Phys
(in press)
VI. - ? More coming, submitted and in draft.
Potential to use ‘Hard Edges’
Limited because there was no formal authority and the ACDS IS
NOT A REGULATOR
The CAG reviewed audit outcomes – this was known to
participants.
The ACDS Reserved the right to proceed ‘up the chain’ within the
hospital.
Further escalation beyond the facility was difficult because the
ACDS and auditee had co-signed an agreement that the audit
outcomes would not be conveyed beyond the facility and the
ACDS.
A Future
Business case for a five year program to deliver IMRT/IGRT, small field, 4DRT
& dynamic arc audits.
The ACDS will no longer be a free service – exact funding model to be
determined.
The Clinical Advisory Group will continue.
ARPANSA Corporate Office will provide governance
Stakeholder Advisory Group will provide input into the ACDS
Management Advisory Group will provide management and policy oversight
Review at 5 years.
Acknowledgements
'The Australian Clinical Dosimetry Service is a joint initiative between
the Department of Health and the Australian Radiation Protection and
Nuclear Safety Agency'
Acknowledgements
'The Australian Clinical Dosimetry Service is a joint initiative between
the Department of Health and the Australian Radiation Protection and
Nuclear Safety Agency'