1. The role of the Advanced Practitioner in the successful implementation and delivery of Image Guided Brachytherapy (IGBT): Katie Bradshaw Cambridge University Hospital

2. Introduction For bulky cervical tumours, MRI based intracavitary techniques with the addition of interstitial needles has been shown to give superior local control rates, with low morbidity. (Johannes et al, 2006). In light of this evidence CUH became the first centre in the UK to implement this relatively new concept in 2009.

3. The Goal… Implement Image Guided Brachytherapy (IGBT) Gain superior local control rates Reduce long term morbidity Provide seamless, patient focussed care!

4. No problem… (Is there an advanced practitioner in the room?) “At this level the radiographer has specialised or developed their knowledge and skills and in relation to clinical practice, the core function will be related to a range of radiotherapy procedures in the delivery of care for patients related to that expertise. The advanced practitioner will be an integral member of the radiography team but will also interact with the wider multi disciplinary team to ensure the delivery of high quality clinical care.” (An update of Education and Professional development: Moving Ahead (CoR) Nov 2003)

5. Implementing service redesign Implementing successful service redesign represents a huge challenge for all staff involved: IGBT is a complex pathway. Daunting experience for most patients. IGBT requires a dedicated specialist team (multidisciplinary team).

6. The (my) mission? (if you choose to accept it!) Identify key individuals. Develop and extend roles. Re-write pathway (complete redesign) Develop protocols Patient information Overcome resistance to change Reassure staff…challenge but exciting Communicate! Motivate + reflect on progress!

7. So how did technique and management differ? Addenbrookes (previous technique) Addenbrookes (IGBT ) TechniqueTandem & RingTandem and ring ± interstitial needles Fractionation21Gy point A in 3# 8 days 28Gy point A in 4# 9 days Schedule3 separate theatre sessions (Mon, Thurs, Mon) 2 theatre sessions (Mon, Tues, Mon, Tues) IP/OP Location OP ONC Day unit IP (X2 overnight stay) ONC Day Unit Gynae Ward Imaging (CT – CT/MR) RT/CT X3RT/CT X4 MRI X2 Analgesia During procedure Applicator removal Oral Entonox Epidural/PCA Epidural

8. Identify ‘key’ individuals In order to facilitate the change identify key individuals. The ‘old’ brachytherapy team: Oncologists Consultant Radiographer Specialist Gynae Radiographer Brachytherapy physicists Oncology Day Unit Nursing Staff RT/CT staff

9. The ‘new’ IGBT team Oncologists Consultant Radiographer Advanced Practitioner HDR Radiographer Diagnostic/RTCT Radiographers Brachytherapy physicists/ treatment planning radiographers Anaesthetist Pain control Team Gynae Surgeons Onc day unit nursing staff Theatre staff Theatre liaison staff (named) SpR’s, Bed manager, porters…. ‘This is where we begin to see the advanced practitioner role becoming pivotal – he/she facilitates the effective communication between the ‘whole’ multidisciplinary team!’

10. Why is clear role definition important? Clear role definition: Prepare for the role Understand the role Clear about objectives Ensure ‘effective’ team working Consider: ‘Takes time to fully implement new roles particularly when forming a dedicated, specialist multidisciplinary team.’

11. Role Development and Extension All staff (at this stage of implementation) had limited IGBT knowledge. Dedicated anaesthetist Diagnostic radiographer  lead with implementation, protocols, co-ordination etc Nursing staff  epidural training Advanced Practitioner  applicator removal (with interstitial needles) Educational and training needs of staff identified and ‘in house’ training programs/competency frameworks developed.

12. Education and training provision The advanced practitioner has a key role in providing education and training for all staff involved in the IGBT pathway. Education and training is essential in any new service and is fundamental to encourage: Clear role definition Effective communication between all staff Role development and extension Staff involvement and engagement Staff enthusiasm, motivation and support Overcoming resistance to change

13. Key points for IGBT teaching sessions … Stress the benefits of treatment – improve cure rates/reduce side-effects Clear pathway definition Importance of maintaining applicator position Pain control Prophylactic anti-diarrhoeal medication Cost of lost equipment (establish a robust tracking system) Importance of good communication Above all, inspire and motivate the audience by your enthusiasm!

14. Overcome resistance to change? Communicate… Staff involvement Training/education Clear role definitions Motivate – Challenging but exciting!

15. Role of Advanced Practitioner within IGBT pathway… Patient consent Pre- operative care Applicator insertion Imaging Dosimetry planning QA checks Treatment delivery Applicator removal Aftercare

16. The Advanced Practitioner facilitates/provides: A full explanation of treatment, benefits/risks Provision of written information Opportunity to ask questions/seek clarification Support, understand and empower the patient through the care pathway. Review/assess patient prior to anaesthetic Smooth pathway by liasing with theatre staff. Support and reassure Continuity of care Patient Consent Pre- operative care

17. Record applicator details (position of interstitial needles) Mark applicator position for monitoring. Communicate between the various professionals to minimise delays Contrast administration Insertion of dummy x-ray catheter wires Selection of scanning volume to ensure coverage of applicator/sufficient anatomy. Applicator Insertion Imaging

18. Provision of all relevant information required to plan treatment. Routine QA checks of brachytherapy machine, auxiliary equipment/operator station. Ensure the safe/correct delivery of treatment Dosimetr y QA Treatmen t Delivery

19. Key competencies Applicator removal is extremely distressing! Familiar face - continuity of care! Identify signs of patient distress/ anxiety and manage effectively. Oncologist input not required, making effective/efficient use of staff resources Source stick! Feminine aftercare: Information and support, post radiotherapy/ brachytherapy changes to vagina/impact on sexual function Provision of ongoing support during follow up Applicator removal Aftercare

20. Am I (are YOU) instrumental? Effective co-ordination of patient pathway, ensuring continuity of care from referral to post radiotherapy. Provision of specialist information about disease, treatment/side effects for patients, relatives and carers. Clinical management of patient, identifying specific needs throughout the pathway, facilitating improved quality of care. Facilitation of effective communication between multidisciplinary team, patients and relatives throughout patient pathway. Education and training provision. Motivation of all involved staff Provide seamless, patient focussed care!

21. Yes! ‘Implementation and smooth delivery of image guided brachytherapy has been overwhelmingly successful at my cancer centre and the role of the advanced practitioner has been and is instrumental.’

22. Katie Bradshaw Advanced Practitioner in Gynae Oncology Oncology Centre, Box 193 Addenbrooke’s NHS Trust Hills Road Cambridge CB2 2QQ Tel: 01223 256710 Bleep: 154-388 Email:katie.bradshaw@addenbrookes.nhs.uk