Safety and Quality Improvements in a Pediatric Total Body Irradiation Procedure
N Cao*, E Ford, M Nyflot, R Ermoian, L Young, K Hendrickson, Department Of Radiation Oncology, University of Washington Medical Center, Seattle, WASU-E-T-232 Sunday 3:00PM - 6:00PM Room: Exhibit Hall
Purpose: Through the use of incident learning, safety-critical areas were identified in our current procedure for pediatric patients undergoing total body irradiation (TBI) for bone-marrow transplant. These are relatively rare and complex procedures requiring non-standard setups and administration of anesthesia. The purpose of this study is to simplify and standardize the simulation and planning procedure for pediatric TBI to improve the safety and quality of care.
Methods: Motivated by near-miss incidents, a systematic review of current TBI procedures was conducted, and the following issues were identified: unclear communication describing variations in setup at simulation versus treatment related to anesthesia requirements, confusion about measurement units, unclear criteria for various setup options to accommodate patients ranging in age from infancy to 7 years, and variations in compensator design methods. To address these issues, a simulation form was designed with detailed instructions and documentation requirements. Dose calculation and tissue compensation procedures were redesigned to remove set-up variations. Calculations were performed on 28 previously-treated patients to determine the dose uniformity with the new vs. old method.
Results: Feedback from clinical staff indicates that the new simulation form improves interdepartmental communication and decreases the risk of treating patients in a setup that differs from that used during the simulation. The new compensator design significantly improved patient dose uniformity: 0.8±0.4% (new method) vs. 4.2±2.3% (old method) (p < 0.01). The data indicates the new compensator design will result in fewer out-of-tolerance in vivo dosimetry readings and reduce associated re-planning efforts, which is especially critical for single-fraction treatment.
Conclusion: For an institution averaging one pediatric TBI case per month, standardization of the procedure simplifies the planning process and improves patient safety. Since there are few technical reports about pediatric TBI, this experience may be especially beneficial for other centers with low volumes of pediatric TBI patients.