Simulated Radiotherapy Set Up - Pelvis

Learning Outcomes

• Knowledge assumed to be in place
  • Familiarity with 4 field brick (4FB) beam arrangement for pelvic Radiotherapy
  • Familiarity with typical treatment record for 4FB, including identification of diagnosis, prescription, immobilization instructions, patient positioning instructions, surface markers, ioscentre shifts, beam parameters, and record of cumulative treatment doses.
  • Knowledge of the need/procedure to correctly identify both patient and treatment site prior to treatment delivery.
  • Need/procedure to check pregnancy status in female patients between the ages of 12-55 years.
  • Appreciation of the need to check clinical status of the patient prior to proceeding with treatment, and under what circumstances treatment might need to be delayed, e.g. if the patient shows signs of altered/deteriorating health since the previous day.
  • Knowledge of correct manual handling procedures for ambulant patients.
  • An understanding of the importance of effective communication with both the patient and the other members of the clinical team during set up.
  • Knowledge of positioning terminology (ANT/POST, SUP/INF etc)
  • Familiarity with linac and couch controls though previous practical training opportunities
  • Appreciation of the need for accuracy in positioning of  patient/couch/machine, and the implications of inattention to detail.
  • Knowledge of the correct sequencing of the individual steps in the set up procedure for 4FB technique.
  • How to calculate couch shifts
  • Knowledge of the beam delivery process from outside of the treatment room, including checking of parameters before switching on, observing the patient and the accumulated dose throughout, knowing when the “auto-set” facility may be safely utilized, and knowing how to terminate the beam if required.
  • Appreciation of the need to set up a communication method with the patient if they experience distress during beam delivery, e.g. waving or intercom
  • Knowledge of how/why to return the machine and couch to a safe position before helping the patient off the couch.
  • Knowledge of common side effects to 4FB technique and their management strategies.

• Skills

  Perform the following actions safely, accurately and in the correct order, in teams of 2 or 3 students:

  • Interpret the treatment prescription and set up instructions from the treatment record
  • Prepare couch and immobilization equipment
  • Greet the standardised patient (SP)
  • Identify the patient and the treatment site
  • Establish the patient’s clinical status
  • Ask the patient to remove appropriate clothing and get on the couch, assisting where necessary
  • Ensure the patient is lying straight and flat
  • Align pseudo-tattoos (stickers on underclothes) to lasers in 3 planes
  • Perform couch shifts using VERT
  • Position linac using VERT
  • Check light beam is appropriately positioned and is not passing through metal couch supports
  • Check all shifts and parameters against treatment record
  • Communicate with SP and other team members throughout the set up
  • Warn the patient that the team are about to leave the room and deliver the treatment
  • Describe the use of the “Last Man Out” button and room entrance interlocks/barrier
  • Describe the actions that would be required to deliver the treatment from the control room, including auto-positioning and checking of subsequent beams, and monitoring the patient throughout
  • Communicate with SP on re-entry to the treatment room
  • Return linac to a safe position using VERT
  • Lower the couch and assist the patient to get off
  • Conclude the treatment session with any special instructions such as confirming the next appointment
  • Escort patient out of the room
  • Ensure couch and equipment are cleaned prior to and following the procedure
  • Discuss the need to wash hands between patients (at start and/or end of procedure)
  • Demonstrate respect for the patient’s modesty throughout the procedure
  • Demonstrate minimal/appropriate touching throughout the procedure

• Attitudes/Behaviours
  • Team work
  • Close attention to detail and accuracy
  • Close attention to safety
  • Appropriate sharing of information
  • Politeness
  • Helpfulness
  • Efficiency
  • Respect for patient’s privacy and dignity
  • Maintenance of confidentiality
  • Empathy
  • Problem solving
  • Being proactive and reactive
  • Recognizing the need for reassurance
  • Recognizing the need to instill confidence in the patient

Scenario Environment

Case Introduction

Prior to attending the simulation students are directed to watch a film of a similar set up and note the order of the individual steps.

On arrival students are given the following information:

Task:

The object of today’s exercise is to bring together everything you know about how to communicate with patients, how to care for their needs, how to position them and how to set up their treatment. Each of these aspects should be familiar to you already through previous practicals but you may not have had the opportunity to bring them all together in an unassisted and unprompted way before.

You will be working with a standardised patient (actor/actress who will play the role of the patient). You will need to do the following:

1. Read through the treatment sheet carefully.
2. Prepare your treatment room. (Please be careful not to knock the lasers out of position.)
3. Collect your patient from the waiting room (bench outside of the classroom).
4. Greet and communicate with your patient appropriately.
5. Position your patient on the couch and align their marks to the lasers.
6. Set up their first beam for treatment using VERT.
7. Talk your lecturer through the procedure for leaving the room and switching the machine on.
8. Set up the second treatment beam on VERT.
9. Talk your lecturer through the switching on procedure.
10. Return the machine to a safe position on VERT.
11. Help your patient off of the couch and conclude their treatment session appropriately.

Throughout the exercise you will need to decide between you who will take which roles, and you will need to communicate with your other team members and your patient throughout.

Please ensure you adhere to safe manual handling protocols, using the minimum amount of manual handling possible and following your manual handling training.

Your patient will be wearing 2 layers of clothing over the treatment area. For the purposes of this simulation, when removing clothing you should only remove the outer layer and treat the inner layer as if it is the patient’s skin. The marks will be on the inner layer of clothing rather than on their actual skin. You should not expose the actor/actress’s actual skin at any point. Remember to use appropriate and minimal touch only. Your lecturer will stop you if they feel that you are not carrying out the task in a suitable way.

Your lecturer will not prompt you or intervene unless they feel that you are behaving in an unsafe or inappropriate way.

You will have 20 minutes to carry out the entire procedure from start to finish, after which time you will have the opportunity to explore your team’s experiences with your lecturer and your patient.

Available Collateral Information

Ground rules are also established including:

• Confidentiality – what happens in the room stays in the room. The standardised patient will also keep details of the simulation confidential.
• Feedback must be constructive and supportive.
• Any other appropriate ground rules as agreed by participants

Prior to commencing the simulation students are given 10 minutes to consider a list of prompts in the form of around 30 questions addressing the key steps of the procedure, e.g. “How will you greet/identify this patent?” “What skin marks would you expect this patient to have?” “How would you protect this patient’s dignity?” “What safety implications do you need to consider?”

During the simulation the group are encouraged to problem solve for themselves if possible. If they get really stuck the facilitator may guide them in general terms to promote further problem solving, e.g. “So far you have aligned lasers to tattoos, but does this mean you are also aligned to the isocenter or might you need to make any further adjustments?” “Are there any other lights on your hand pendant that might help you?” “That information should already be available to you in the treatment record. Take a closer look.” “Does anyone else in the team have any ideas how to overcome this issue?” Students are provided with a written guide on how to calculate couch shifts, which they will have already been familiar with from previous practical sessions.

Facilitators are encouraged not to give out any further information about the set up procedure directly as everything should already be available in the treatment record. Where students ask questions that are not directly relevant the facilitator should state this rather than allowing the students to get side tracked.

The one part of the procedure that will not have been practiced before and will have only been discussed in theory is the switching on of the linac from the control room, including the auto-setting of subsequent beams, although students will have observed this through the preparatory film and during a clinical observation day. This stage cannot be physically simulated at our university and is therefore covered by discussion at the relevant stage in the simulation event. Facilitators will lead a discussion at this point and may answer any relevant questions.

Instructions for standardised patient

The SP is asked to choose a false identity that they can easily remember and this is then added to the treatment record.

The set up procedure is descried to the SP in a face-to-face meeting and questions are encouraged. A written description of the set up procedure is also provided. SP’s can be directed to publicly available patient information videos such as the one below if they want further information about what treatment entails. This particular example is produced by one of our clinical partners and offered to real patients who are about to undergo Radiotherapy.

Radiotherapy | Royal United Hospitals Bath (ruh.nhs.uk)

Clothing instructions are provided as stated above, i.e. tight fitting under layer and loose fitting outer layer on pelvis. SP’s are made aware that students will either ask them to remove/ease down the outer layer or may ease it down themselves. They should also expect the students to touch them gently around the hip and buttock area for positioning purposes as well as shoulders and ankles for straightening purposes. The minimal and appropriate touch approach is explained and SP’s are asked to confirm that they are happy with being touched and positioned. They are instructed to be helpful if asked to move in to position themselves, and to ask if they are unsure what the student wants them to do. If they feel that the student is touching them in a rough or unnecessarily intimate way they are encouraged to challenge that verbally, e.g. “That feels uncomfortable” and/or to make the facilitator aware that they wish the procedure to stop.

The SP is directed to the waiting area at the start of the procedure and asked to respond when called through for treatment and asked to confirm their identity and treatment site. They may use any acceptable language to describe the treatment site, e.g. “pelvis”, “bladder”, or may point to the appropriate area on their own body, in accordance with the way patients might typically respond in a real radiotherapy department.

The SP is made aware that they will be asked how they are feeling. They are made aware that they are only 4 days in to a 6 week treatment and should not have experienced any side effects yet other than tiredness from the daily travelling and should respond accordingly.

The SP is made aware that they may or may not be asked to remove their shoes before getting on the couch and should do so if asked but not comment if they are not asked.  They should then get on the couch when asked and should be aware that students may assist gently, e.g. by guiding their feet up on to the couch or placing a supportive hand between their shoulder blades as they lie down. SP’s are directed to decline any other help is offered e.g. “No, I can manage thanks” and warned to ask the student loudly to stop if any attempt is made to physically handle them inappropriately, e.g. lifting their legs before they are ready to lie down.

The SP is made aware of the expected position and is encouraged to speak up if anything feels obviously different, e.g. “Don’t I usually have a pad under me head?”.

The SP is made aware that the procedure will probably take the students longer in this practice situation than it might in an actual department, and they should be prepared to be ignored for a short period while students concentrate on setting machine parameters. But if this period seems to be uncomfortably long, e.g. nobody has spoken to them for around 5 minutes, they should comment, e.g. “It doesn’t usually take this long. Is everything okay?”. Similarly, they should be encouraged to question anything that they believe may sound worrying to an actual patient, e.g. if students are arguing over the right machine settings or shifts within the patient’s earshot.

The SP is made aware that some of the set up will take place on VERT and that it is reasonable for the student to forget to talk to them during this particular period due to their attention being drawn away from them during this artificial setting. Their patience is encouraged. They are shown VERT in advance so that they understand what is happening on the screen behind them  as they won’t be able to see it while lying on the treatment couch.

The SP is reassured that there is no possibility at all that they will be exposed to radiation at any point.

The SP is warned that the electronic couch will be raised to a workable height once they are on it and that they should not attempt to get off again until told that it is safe to do so. They are told to expect verbal instructions from the students and to ask “Can I get off now?” at the end of the procedure if no such instructions are issued. If asked if they need help getting off they are told to politely refuse, but to allow gentle guidance such as a supportive hand between the shoulder blades on sitting up. (Note – only able bodied SP’s who can lie down and sit up by themselves are recruited for this particular simulation activity.)

The SP is briefed about common follow up questions that they may be asked after the procedure such as “do you know your appointment time for tomorrow?” and instructed how to respond. They are asked not to add any unnecessary layers of difficulty at any stage, e.g. not saying they suddenly feel unwell, as the focus needs to be on standard procedures at this year 1 level.

The SP is encouraged to offer feedback on how it felt for them after the event, e.g. “It was a little unnerving not knowing what was going on”.

Any additional questions from SP’s are invited at the end of the briefing meeting.

Evaluation Strategy

Each group’s progress will be informally evaluated by the facilitator verbally against the following criteria:

1. Did the students work as a team?
2. Did the team communicate effectively with each other and with the patient?
3. Were the required machine and patient positions achieved accurately?
4. Was safety considered?
5. Was patient dignity preserved?

These points will not be overtly listed or scored. Students will be encouraged to participate in the debrief first, and then the facilitator will add their feedback using the above points as a guide. No pass/fail judgement will be offered.

Debrief after simulated activity

The participating students are encouraged to evaluate their own performance, focusing on how they felt about the experience, what went well/not so well in their opinion, and what, if anything, they might do differently next time. Discussion is monitored by the facilitator to ensure that all feedback is constructive and that no individual is singled out or judge for their role in the team.

The facilitator may then add further tips/advice and clarify areas of good practice, using the bullet points listed on the previous section as a guide. The emphasis should remain positive, focusing on what has been achieved, how they can improve and when they can next expect an opportunity to practice key skills again in future.

The SP is encouraged to add any feedback about how the experience felt for them. Where the SP offers negative feedback, e.g. “It felt a bit unnerving …..” the facilitator is encouraged to refocus this in to positive action, e.g. “So how can we reassure the patient more effectively in future?” rather than focusing on the cause of the anxiety.

Students are then encouraged to identify one key learning point each that they will take forward in to their future practice.