'Beyond Bricks and Mortar - Building Quality Clinical Cancer Services' Symposium 2011

Building Road to Quality - Mr Leigh Smith & Ms J Smylie

Up to Radiation Oncology

prev pageprev page| TOC |next page

Chief Radiation Therapist, William Buckland Radiotherapy Centre, the Alfred Hospital

Radiotherapy Manager, William Buckland Radiotherapy Gippsland

Download powerpoint presentation by Jo Smylie & Leigh Smith (PDF 3222 KB)

Introduction by Norman Swan:

Just a bit of housekeeping here for this afternoon, so it's a parallel session; one room here, one room there. That means they'll come in and put a partition down the middle of the room during lunch and it might be a bit like the Berlin Wall when it comes to your possessions, so I would make sure your possessions are on either one side of the Berlin Wall or the other, just in case there's a random reallocation.

The other thing that will happen this afternoon is that I'm chairing one session, Leigh's chairing the other. We'll finish five minutes early because the rooms will have to be then redivided so there's a slightly shorter period for the afternoon session but not drastically. But if we could ask the speakers to make sure they keep to time that would be terrific.

The Options Paper is on your table, it's those blue books, those blue books on the front of your table there. There's not one for everybody unfortunately. There's three spare on this table because this table doesn't have a lot of people sitting at it, and so have a look, but not to the detriment of the speakers who spent a lot of time preparing their presentations. And Leigh Smith is going to outline some of the things that are in the Options to you. Leigh is Chief Radiation Therapist at William Buckland at the Alfred, which also looks after Traralgon and Josephine Smylie, Jo Smylie, also works at William Buckland and they're going to share this presentation about building roads to quality.

Leigh Smith:

Thanks Norman. I've noticed there's been a theme running through the talks of travel, roads and distance and I'll continue that theme. Here we’ve got Australia’s highway, the Princes Highway, and it was cut in February with rain and the road started to subside. This is the umbilical cord between the Alfred and Traralgon. We do a lot of travelling up and down this highway and it’s our number one road, and it’s not fixed yet. On the left of the picture there, that’s the Yallourn open cut coal mine that the road’s falling into. I’ll resist the urge to talk about working at the coal face. So it’s a road well travelled by us. The analogy that I make is that the detour around that problem is through Morwell now, and there’s always a way around a problem and that’s been true to say in regard to setting up and working at Traralgon.

Just a bit of background about the satellite centre we run at Traralgon. It’s called William Buckland Radiotherapy Centre, Gippsland. It’s part of the GCCC and it’s hosted by Latrobe Regional Hospital, which is the major hospital for the area, the Latrobe Valley and pretty much Gippsland. The hospital is actually located a couple of k’s out of Traralgon. It’s in the Latrobe Valley, as I say, 150k’s from Melbourne and it was one of three centres established as part of the SMU trial in the early 2000’s. It started some time after Bendigo and Ballarat, we weren’t clinical until July 2006, whereas Bendigo and Ballarat started in 2002.

Just some relative population numbers for the cities we’re talking about here. The total Gippsland population is about a quarter of a million, Traralgon is only 22,000 itself but there are nearby towns which swell that number to 80-90,000. There is Morwell, Moe and some towns like Warrigal further up the line which swell that number. Orange, which is a recent regional centre opening up in NSW, they’re about 38,000 but Bendigo and Ballarat have significantly larger local populations, in the 90,000’s. So that’s just some relative numbers.

How is it organised down at Traralgon? Well, it’s a joint venture between the two hospitals – Latrobe Regional and the Alfred. It’s on the hub and spoke model. We’ve heard quite a bit about hub and spoke models and we would consider that a vital component of how it is organised. The buildings, the infrastructure and the equipment itself, the linear accelerators and so on are owned by LRH. They own the capital. The Alfred staffs the service and provides the radiotherapy expertise with the medical staff, RT’s, medical physicists and the data management team employed by the Alfred. Latrobe Regional employs the nursing staff, the admin and clerical people. The operating budget for it rests with the Alfred. I think the point I’m making here is that not one of the three single machine units are set up identically, we’re all a little bit different in subtle ways.

The equipment we have. Well the first linac was installed in 2006, we have a skin unit and we’ve got a dedicated GE 16 slice CT scanner. As we speak, the second linear accelerator is going in now. It’s being commissioned with all the goodies of RapidArc® and OBI and when that is commissioned and clinical, we will retrofit the existing machine with the same technology, so that we have two matched machines. The point I would make here is that as a single machine unit, it’s really important to become not a single machine unit as quickly as you can, and I’ll explain why later.

Just a pretty picture of the department at Traralgon. There was a pot of gold at the end of that rainbow and the Federal Government actually came good with some money at the end of last to year to extend the facility by the second linac and plans are on the drawing board at the moment for the third bunker there and a footprint for the fourth. The services we weren’t supposed to engage in when the SMU first opened up, is that list there. So we weren’t expected, or were not anticipated to, tackle these diseases. Over time, there has been pressure from the local people, to try to treat certain things there and the next slide will indicate that we are now treating some head and neck cases, some haematological conditions, and that’s grown with our doctors travelling down the road, being able to provide subspecialisation into these tumour streams, as time has gone on. I think the other SMU’s felt the same pressure for patients to be treated at their regional site, even though they were disease sites we weren’t supposed to be tackling. I think head and neck, probably, is one.

So quality is a mix of many issues, we believe and the ones I have highlighted here, I will just elaborate a little further down the talk – we’ll talk about workforce, planning for the future, ensuring technical quality at both sites is equitable and transport and accommodation is a big one too. Again, that travelling distance road theme. I’ll just skip through quickly on the ones we’re not going to elaborate on. Two organisations in running this service, we actually are the meat in the sandwich between two organisations, the Alfred and Latrobe. We’ve seen significant executive regime change at both organisations, so we’ve had to re-establish relationships at both ends with our respective executives. Rebuild those relationships in collaboration, you know two sets of IT groups of both ends, we have two firewalls, two difficult groups to work with, I won’t go on, I’m sure you know about the IT issues and how fraught it can be. The importance of the hub and spoke model cannot be overstated. I think we have been in very precarious times at times, since 2006, where we would have only needed one or two things to fall over and it would have been a very unviable service to be maintained. Fortunately we skipped through those times safely, that was because we had a hub and spoke model in place and we could lend support to travel people down the road, or trainline, to Traralgon, to lend that support as needed.

IT and linkages, talk about that. Multi-disciplinary care – that’s been one of the success stories down at Traralgon, that they really are progressing quite well with setting up MDT groups down there. We have GI palliative care about to start, lung, urology, breast and another few I can’t recall, but Jo might mention them along the way.

So we’ll move on and I’m just gonna talk about the issues related to a single linear accelerator and we will plonk in some excerpts from the standards themselves, just to show the relativity of the relationship to the standards that these last two days have partly been about.

This is Standard No. 6 about facility process management and talking about the provision of timely co-ordinated care and about the required evidence we look for in that standard and dealing with unscheduled treatment interruptions and you can all make the leap to what that means in terms of a single linear accelerator. This is just some quotations from a Royal College of Radiologists document which came out in 2008 about the impact of unscheduled treatment interruptions and the importance of radical courses of radiotherapy not being interrupted. The longer the gap, the more damage that’s done, but we can actually predict many of these interruptions, such as service days, and we can work around things. Of the five major causes of delay, obviously machine and staff availability – that’s a no brainer. Public holidays are a problem in a small site. We’ve had some long public holiday breaks in recent times, with Easter attached to Anzac day this year and Christmas breaks. They need to be managed.

I don’t need to state the obvious here, but they break down and they break down often. We’ve had one down for three weeks once at the Alfred, fortunately we haven’t had that experience at Traralgon. Engineer response times from the city are two hours door to door from the Alfred, depending on where the engineer is. What to do about breakdowns, public holidays, service days, difficult to work around service days when you’ve only got one machine, access to the machine for the physicist to do routine QA and increasing technology of our machines means more servicing of them. Each component needs its own service aspect. That’s just a linac that’s closed off and being furbished. So not only the linac needs to be furnished, it’s the MLC, it’s the EPI, it’s the OBI. They all need to be attended to so it adds time to the servicing.

Medical impact from the RCI document – one week delay fairly significant impact, median control reduced by about 14%. A one day interruption, 1-1.4% impact for a head and neck case, cervix, lung.

So strategies, what do we do about the single linac. First line maintenance by staff, I think Judy and the crew at Bendigo pioneered some of that work, with RT’s taking on first line maintenance, being able to change MLC motors, that sort of thing, can avoid the niggly little delays of waiting for an engineer to turn up. Changing service schedules – we’ve done it at the Alfred, we’ve got four machines there and we now service the machines back to back over a two week period, four times a year, so that every patient gets treated now during service periods, no patient doesn’t get treated because of a service of machine. It’s easier to do when you’ve got four machines, because you’re just shifting one load at a time, spread across three machines. Not quite as simple, even with two machines, but it can be done. And of course, the matching of two machines at Traralgon would be a bonus in the future, being able to shift patients during breakdowns.

Better planning for public holidays. It’s a fine line between treating everybody and treating the Category 1 patients that the RCR document talks about, the ones that really should be treated five days a week. And planning for a second linear accelerator, which is what we’ve been doing up till now and that’s reality, as it’s being commissioned now.

I’ll hand over to Jo now, Jo’s going to take you through the other quality issues that we highlighted before, being workforce and the others, and again, here’s the standards that Jo will talk to.
Top of page
Josephine Smylie:

Thanks Leigh. Basically, we’re going to talk about the first two standards in the Radiation Oncology planning standards, and they relate to workforce and staff. It’s about ensuring that the staffing numbers are adequate to deliver the service. So our current service, we should have two radiation oncologists, we have 1.2, we’re fine for radiation therapists and medical physicists we only have one and we’ve recently appointed a registrar and we do have a radiation oncology registrar but it’s an unaccredited position. So if you look at this complement and then think about the second linac coming on board, we’re obviously going to have to double that complement. Given the difficulties we’ve already had, I presume that our build up will be incremental.

So what’s happened at that site? You’re looking at the girl who tried to tear her hair out in 2006 and 2007 and just wonder how we were going to survive. When we started this service, we had one radiation oncologist, one physicist and five radiation therapists and you can see from the graph that our workload built up very quickly, even in the first year. Now, it’s fairly obvious that in the medical arena, as Jeremy alluded to and in physics, we are way below the benchmarks into what we should have. So how did we survive, and that’s about that road. Basically, it’s the hub site supporting its spoke and sending staff down the road so that we could manage our workload. So it was really essential to have that model and have the support from the major site. The other aspect to it is that amongst the radiation therapy group particularly, we had some very old radiation therapists and some very young radiation therapists and not many in the middle. So there was a tremendous burden on the senior radiation therapists in order to do service development and any of those other activities. So what we have to do is when we’re on leave, or when we needed time, then basically the hub site had to send senior staff members down to release us to do the work. In any situation like this, professional isolation is really a key issue and you really have to continue to work at that, no matter what your staffing complement is in a hub and spoke model – it’s vital.

So what strategies did we put into place. The obvious thing when you get really, really busy and you don't have enough resources, is that you start building a waiting list. You start perhaps triaging your patients, sending them to Melbourne if you cannot manage. In the early days, there were times that the waiting list actually pushed out to five to six weeks. So to manage that we took a totally different idea, in that we decided to manage the workforce, rather than the workload and we’ve continued that. The important aspect of that is that when the waiting list builds, we contact our hub site, we arrange for extra resources if we need them and then we extend our hours. So that is a really important part of the way we operate as a service. You really have to be very careful not to burn out your existing staff by extending the working hours, when they are a particularly limited group. We’ve had awful issues with recruitment.

We’ve talked about medicos, we’ve talked about physicists. For the radiation therapists, it has taken us five years to develop a full complement of staff. So the strategies we have put into place are basically financial support in terms of relocation and cost of living adjustments, ensuring that we invest very heavily in staff development and also investing in the junior staff and their development. We’ve put in advanced practice amongst the radiation therapists, to try and help our radiation oncology colleagues and so now we do RT and nurse led treatment reviews and we also have two of our colleagues who can do breast simulation and are qualified to do so. You need to have the technology to particularly attract youth and to show that the centre is actually not just, if you like, a basic centre but has the capacity to grow and mature as you go. Hopefully in future we will develop a research capability, we’re starting to talk about that, the second linac gives that opportunity.

We’ve worked hard to target the local students and our interns and I have to say we’ve been really fortunate that every intern we’ve taken on has stayed with us. So investing in that youth has really been a good outcome for us.

So the next thing we wanted to look at is planning for the future. Standard 5 talks about facility infrastructure and that promotes safe quality care and accountability in the delivery of the service. One of the evidence required is that you have a strategic planning piece and a timeframe for what happens. So we’ve been rather fortunate. This was the dream, we have the plan sort of superimposed on Latrobe Regional Hospital and of course we’re not there. That’s the Gippsland Cancer Care Centre. However, to the credit of Latrobe Regional Hospital, they have done their master planning for their site and if you look at this picture, their expansion will go towards the back and out to the left hand side.

Now if you think about where we’re located, the important thing is for us not to be land-locked. So what Latrobe have done, in the purple area, that’s the existing Gippsland Cancer Care Centre, that will be expanded to another level and have medical oncology and clinics on another level upstairs and the green area is the second bunker that’s going to be built. So the expansion to upstairs and the second bunker is part of the money that was given by the Federal Government. If you can see the white dotted line, that’s the footprint for the fourth bunker. So what we are assured of is that we are not going to get, if you like, land-locked in by the rest of the hospital. They’ve done their work very well.

The next area we wanted to look at is treatment delivery. That’s Standard 11. It talks about the delivery being correct, accurate, safe and consistent and basically the criteria is there that you’ve got verification procedures, that minimise the risk of incorrect patient dose and anatomical treatment misplacement. We want to just look at some of the required evidence, which was a documented audit of images to check that we had the right treatment delivery site. So it’s very important, when technological advances are made, that you stay in sync with your hub site and what occurs there.

Now, this is probably like teaching somebody to suck eggs. This is about fiducial markers in prostates. It’s been around for a long time, where we simply put the markers into the prostate and then we match our imaging from treatment to those markers, on a day to day basis, to check that we’re in the right place. So essentially that’s what we wanted to do. This is just a digitally reconstructed radiograph. You can see there the fiducial markers and they’ve been highlighted in that, so that’s done at the planning stage. A lot of you are very familiar with these images. Here’s an image from the treatment unit and you can actually see the fiducial markers, and you can also see that the image taken shows that they’re not matching. So the arrow indicates the level of shift that we’re going to make for that patient before we treat them and there’s the image, the shift made and we can go ahead and correctly treat the patient. So sounds really good.

So how do you do it when you’re out in a regional service, what are you going to do them?

It was well established at the Alfred, but from our point of view we had to sort out a few issues. It took 18 months for us to sort out how to implement this process locally and the reason being that we had limited urologists available and those who are in the hospital are doing theatre lists and not consultations and the rest of them are private practitioners who are diversely located through the region. We have an external private radiology provider, so we had to approach that provider to see if they could provide assistance with putting the seeds into the patients. We finally did find a radiologist who was willing to make that commitment and so we’ve been able to achieve that, but we have one radiologist who does this process. So if the radiologist goes on leave, it can be a little bit problematic.

The other thing we had to sort out, because it’s a private practice, is the billing arrangements. Fortunately for us, they’ve agreed to bulk bill the patient so there’s no cost to the patient. There is a down side. The ultrasound rectal probe is at Warrigal, which is 45 minutes away, so patients have to travel to Warrigal to have their seeds implemented. But we did get there, that’s the important thing, which is what Leigh was saying – you can always find a way around things if you’re willing to look at alternatives and negotiate.

I put this up because I thought we had a big region like Barwon and people travelled a lot of distance and when you look at the distance between Traralgon and basically out to Mallacoota, that’s a four to five hour drive for a patient, one way. But it pales into insignificance to what Sean has given us today from Townsville. But it’s a really important issue for the patients of the region and what it means is that you have to have local, affordable accommodation available for patients, and the closer the better. When we started, there was no accommodation available for patients, so we hiked ourselves around every motel in the region and did deals with caravan parks and motels, so we could find patient accommodation. Then by September 2006 we had Rotary Centenary House, which was funded by community fundraising and a grant from the Federal Government. There were seven rooms available and that was fantastic, although sometimes difficult to get patients into. So we still utilised the caravan parks and the other motels. Currently Centenary House is being doubled in size, thanks to a grant from the Federal Government last year, and so that’s really fantastic and that’s a self catered facility and I know that patients really like it. The other options still available, and I think Ian will appreciate this, you have to have something because people want to bring pets with them. You know, there are all sorts of issues which are there for patients and you need to accommodate those things. The caravan parks, some of the motels will do that for us. So we’ve got flexibility and the other thing we need to have is flexibility for those who don’t want to travel. We have patients who are quite happy to travel two hours a day because they are farmers, they’ve got commitments, but when they get tired, they need instant access to accommodation.

This is just an aerial photograph of what’s located around. You can see Centenary House, where we are in the green, and a couple of caravan parks and the motel next door. The motel next door is a 4 ½ star motel, so a little expensive for patients. The other motels are quite a long way away and when we utilise those we have to actually look at the next aspect of things, which is transport for patients coming for treatment. So patient transport, I have to tell you that when we started there, there was a bus that went past the hospital that stopped somewhere on the Princes Highway, but no bus came into Latrobe Regional Hospital. It took the hospital two years to convince the bus line to build a bus stop, so that patients could use it. So we now have that, but most of our patients were reliant on their own transport, or Red Cross, or volunteers or DVA or ambulance.

For the local patients it was public transport and taxis. We do have a volunteer car that we can use for patients and Centenary House has a courtesy car. These things are very important in terms of trying to deal with patients and minimise, if you like, the anxiety for them. So they need accommodation, transport, support all sorted out before they commence on their treatment and all the way through it. I think the point I want to make here is that every one of our patients sees our social worker and every week we meet to discuss the patients who are on treatment and look at all the other aspects of supporting those patients. It’s been a very successful thing to do.

So in summary, there’s the road, extremely well travelled. It allows you to import policies and procedures from your hub site, which make it very convenient. The hub and spoke model is really important in ensuring quality and viability. You need to plan for your future, two linear accelerators, of course, is better than one and delays and interruptions can be managed. The technical quality of care should be equitable between centres and you must consider the supporting infrastructure. So, we’ve done the journey and we remain committed to quality for patients and I’m sure there will be challenges in the future as we progress, but you just need to look at ways around it.

So I’d like to thank the staff at the Alfred and Latrobe Regional Hospital, particularly those at William Buckland Radiotherapy Centre and those at William Buckland Radiotherapy Gippsland and they are the references we use in this presentation.

Thank you.

(applause)
Top of page
Norman Swan:

So what are your outcomes, compared to having it done at the Alfred?

Jo Smylie:

I think they’re no different, we did an audit last year.

Leigh Smith:

Yeah we did an annual audit. We present an annual audit every December and we’ve got a very good patient database and we can’t detect any difference in the outcomes for major groups of patients.

Norman Swan:

Jeremy spoke yesterday about the trouble getting multi-disciplinary teams together at Traralgon.

Leigh Smith:

It’s taken time....I’ll let you speak to that one Jo.

Jo Smylie:

In terms of multi-disciplinary team, it’s taken time and it’s been actually through the Integrated Cancer Services groups that the multi-disciplinary meetings have been set up. We’ve had a weekly meeting for some time, but it’s not necessarily all inclusive and you won’t generally get all the specialists from the region. We’ve got it in breast, skin, GI, we’ve started it in lung, we’ve started an initiative ourselves in terms of palliative care. The Calvary Palliative Care Team at Bethlehem Hospital visit the region and we’ve just implemented a monthly palliative care clinic for our radiotherapy patients. It is challenging to create the networks in a region and if I said to you, if you go out beyond Sale, there are no specialists, there are only GPs. So those sort of things can be really challenging and most of the specialists are actually VMO’s or visiting. So there are challenges there.

Norman Swan:

Thank you very much to you both.

(applause)

Top of page

prev pageprev page| TOC |next page