Ruth Van Davelaar RTT/MHA, Director Radiation Oncology/Radiosurgery, Riverside Health SystemSurface-Guided Radiation Therapy (SGRT) is transforming radiation oncology by enhancing patient safety, accuracy, and comfort. For cancer center administrators, adopting SGRT can seem daunting, particularly in a multi-linac, multi-vendor, and multi-site environment. Riverside Health System, serving Southeastern Virginia with centers in Newport News, Williamsburg, Gloucester, and Onancock, recently navigated this journey—and our experience offers key insights for administrators considering SGRT implementation.
Why SGRT?
Riverside first evaluated the need for SGRT when we were purchasing a new linac. We wanted a robust system that would advance our process for patient positioning and enable patient- friendly Deep Inspiration Breath Hold (DIBH). It was important for us to have a system that would work well in our multi-vendor environment. With the recent purchase of three new linacs, we chose to add SGRT systems to each because we believed it would enable us to improve patient outcomes and operational efficiency. SGRT provides real-time surface monitoring, ensuring precise patient positioning, can reduce reliance on ionizing radiation for setup, and can eliminate the need for permanent tattoos or marks on patients’ skin. For patients requiring SGRT, C-RAD also offers an intuitive visual cueing system that improves compliance and comfort by involving the patient in the process.
Key Considerations in Evaluating SGRT Vendors
We currently have C-RAD installed at two of our four sites and are planning to roll-it out to the others as we purchase replacement linacs in the next 1-4 years. Our site in Williamsburg uses SGRT with Varian equipment and the Elekta MOSAIQ® oncology information system, and our site in Newport News uses SGRT on Varian and Elekta equipment, also utilizing MOSAIQ. C-RAD is also installed in our CT Simulator rooms at both locations, providing the opportunity for patient coaching prior to DIBH treatment on the linac.
For multi-site/multi-vendor organizations like ours, early attention to technology compatibility, IT readiness, and team engagement paved the way for success. Since we have diverse equipment vendors, it was important to be very specific about our evaluation criteria as reviewed SGRT technology providers.
We focused our SGRT evaluation in three areas:
1. Compatibility Across Platforms: Ensuring the SGRT system worked seamlessly with new linacs from multiple vendors, and in simulation, where we have Philips Big Bore CTs.
2. IT Infrastructure: Assessing network requirements, data storage, and security considerations.
3. Workflow Integration: Anticipating how SGRT would fit into existing treatment planning and delivery processes.
I would also strongly recommend that administrative leaders consider billing and compliance early in the process. We engaged our billing company to ensure we understood when to charge motion management, and what specific documentation is needed to support the charge. Since SGRT is billable under certain conditions, we prioritized aligning workflows with requirements from the outset to ensure billing compliance and reimbursement.
Strategies for Smooth Implementation
Riverside’s success stemmed from a structured, collaborative approach, involving a multi-disciplinary team.
- Team Engagement: It was important to our process that our entire team was involved from the beginning. We needed support and feedback from our radiation oncologists, physicists, radiation therapists, nurses and Oncology IT specialist as we navigated through the process. We started with a deep dive into the technology and features presented by different vendors who offer surface-guided technology. We asked questions about the technical aspects of the systems, the workflow, and how the radiation therapists would interact with the system daily. We chose C-RAD as the SGRT solution of choice with the purchase of new replacement linear accelerators. We then coordinated the efforts of the project manager for the linac replacement, the C-RAD service manager, the architects, our IT specialist and physics to ensure C-RAD would be a seamless addition to the overall project.
- Training and Education: C-RAD provided comprehensive staff training, with clinical applications specialists on site for go-live at each location. The training included both Sentinel and Catalyst training, with follow-up for advanced training. Training included virtual sessions and on-site applications so that the team could gain confidence before and during go-live.
- Workflow Adjustments: Our team held C-RAD launch meetings to discuss workflow, logistics, billing and documentation, policy and QA protocols, with the goal being a collaborative and confident workflow in the use of -C-RAD. Our first clinical priority was implementation of DIBH in a safe and accurate manner, with staff and patient comfort aligned with accurate delivery. Our second priority was the use of the surface guided system for enhanced patient setup. Although we have not moved to tattoo-less yet, we see this as a next important step.
Clinical and Operational Benefits
After 12 months of SGRT use, I can report measurable improvements on behalf of our organization:
- Enhanced Quality: DIBH with C-RAD enables us to deliver lung and heart sparing treatment for left-sided breast cancer patients accurately, safely and with patient involvement. We involve nursing in teaching prior to simulation, so that patients will be prepared to hold their breath while in the supine position. Patients also watch a video we created in-house to help explain the coaching lights and what to expect during simulation and treatment. Our RTT supervisor, Felicity Achong, also adds “With C-RAD, patients can better hold and control their breath by watching the coaching lights change color until they reach green, and intuitively, green is good. It helps our RTTs deliver treatments safely and efficiently.”
- Enhanced Patient Safety: Real-time motion monitoring improves treatment accuracy by ensuring that we treat with the imaging we have captured. In the days of treatment complexity, advanced technology, multiple screens and tasks needed to administer quality treatment, having this type of additional support is invaluable.
- Improved Patient Experience: We also have cAutoVerify, which uses facial recognition to validate that the patient entering the treatment vault is the patient pulled up for treatment. It’s automatic and provides additional comfort for the patients that we are prepared specifically for them, in addition to our daily time-out.
- Operational Efficiency: After gaining proficiency, it is quick to raise the table and adjust the patient using the skin surface rendering and set table parameters prior to image acquisition. Faster, more consistent setups have increased patient throughput, optimizing machine time and staff resources.
”In the days of treatment complexity, advanced technology, multiple screens and tasks needed to administer quality treatment, having this type of additional support is invaluable.
Final Takeaways for Administrators
Implementing SGRT requires upfront planning, but the payoff is substantial. Beyond the obvious clinical benefits for improved accuracy and safety, our patients have also experienced greater comfort with the treatments and engagement in the process. Our experience demonstrates thatwith strategic planning and detailed implementation, SGRT adoption can be a smooth transition that elevates both patient care and organizational performance.
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