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A Place for Everything and Everything in Its Place - Standardized Treatment Directives to Communicate Radiation Oncologist Intent

At CancerCare Manitoba all radiation treatments are initiated by completion of a “Treatment Directive” document in our electronic medical record (ARIA VRO). This is done for each new radiotherapy start by the Radiation Oncologist (RO).  The treatment directive is a master document that outlines all pertinent details of a patient’s planned radiation treatment.

These documents are organized as site-specific templates incorporating dynamic form fields for the ROs to populate with metrics regarding the patient treatment. When the radiation therapy department adopted a paperless workflow, meetings were held with all of the disease site groups (DSGs), and standard options were adopted for prescription doses and organ at risk (OAR) metrics in order to encourage consistency among physicians. As treatment approaches evolve and new techniques are introduced, the treatment directives are updated in consultation with the DSGs to reflect these changes. 

Although the options within each treatment directive are limited, there are currently 50 different treatment directives in ARIA, accounting for nearly all possible treatment options, including clinical trials. For patients with unusual disease, one of the standard templates is modified in consultation with physics or a “general” treatment directive is available with a large number of free-form fields. For palliative boney metastasis treatments, standard field borders were adopted for sites including hip, proximal femur, shoulder joint, spine and sacrum.

Each treatment directive consists of two sections:

  • treatment planning information

treatment intent
pacemaker information
drop-down fields with target volumes and expansions
drop-down fields for dose prescription
coverage metrics
planning approach (RapidArc or 3D conformal)
OAR tolerances
in-vivo dosimeter requirements

  • scheduling/simulation information

treatment energy
immobilization device
CT scanning boundaries
previous radiation treatment information
oral/IV contrast
triage booking guidelines
chemotherapy/surgery information
bladder filling/hip pins/bolus
on-treatment and post-treatment follow-up guidelines

By incorporating standard information in a consistent layout, the treatment directives provide clear communication from the RO to the booking clerks, therapists, dosimetrists and physicists regarding their treatment intentions. This communication approach has important safety implications: the drop-downs and check-boxes can be quickly completed and reviewed, which reduces the risk of missing information, errors, replans and delays associated with miscommunications. Changes to the prescription dose are recorded in the treatment directive to ensure that the patient’s plan reflects the RO’s most recent intentions. We have also incorporated an “Amendments to Tx Dir” field to improve communication of treatment directive changes to all staff. The standardization and documentation format further allows for efficiencies and safety features such as site-specific structure templates, clinical protocols and quality assurance scripts to be incorporated in the treatment planning system (Varian Eclipse).