Radiation Therapy - External Beam Operations Manual

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Canberra Hospital and Health Services

Operations Manual
Radiation Therapy: External Beam Radiation Therapy
Contents
Contents ..................................................................................................................................... 1
Introduction................................................................................................................................ 7
Scope .......................................................................................................................................... 7
Background................................................................................................................................. 7
Key Objectives ............................................................................................................................ 7
Section 1 – Treatment Area General Information ..................................................................... 7
1.1 Introduction ................................................................................................................. 7
1.2 Radiation Therapists Staff Organisation ...................................................................... 8
1.3 Radiation Therapist Responsibilities ......................................................................... 10
1.4 Linac Start-up and Handover ..................................................................................... 10
1.5 Daily Machine Geometry Quality Assurance ............................................................. 11
1.6 Treatment Delivery .................................................................................................... 11
1.6.1 Starting a New Case ................................................................................................ 12
1.6.2 Team Work Guidelines ............................................................................................ 12
1.6.3 Notes on Patient Set-Ups ........................................................................................ 13
1.6.4 Billing Procedures .................................................................................................... 14
1.6.5 Verification Images.................................................................................................. 14
1.6.6 Weekly Chart Checks ............................................................................................... 15
1.6.7 Patient Reviews ....................................................................................................... 15
1.6.8 Course Completions ................................................................................................ 16
1.6.9 Close of Business ..................................................................................................... 16
1. 6.10 Quality Assurance ................................................................................................. 16
1.6.11 Personal Stabilisation Devices ............................................................................... 16
1.6.12 Other Matters........................................................................................................ 17
1.7 Annual Business ......................................................................................................... 17
1.8 Fault Documentation ................................................................................................. 17
1.8.1 LINAC Faults preventing the progression of treatment .......................................... 18
1.8.2 LINAC Faults not preventing the progression of treatment ................................... 19
Doc Number Version Issued Review Date Area Responsible Page

CHHS16/204 1 02/11/2016 01/09/2019 CACHS - Radiation Oncology 1 of 117
Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
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1.8.3 Faulty Accessory Equipment ................................................................................... 19

1.9 Machine Breakdowns ................................................................................................ 19
1.10 Transport from Wards, Hospitals & Community ................................................... 21
1.11 Safety ..................................................................................................................... 21
1.11.1 General Safety ....................................................................................................... 22
1.11.2 Shielding Blocks Safety .......................................................................................... 22
1.12 Accident & Incidents .............................................................................................. 23
1.13 Loss/Theft/Property Damage ................................................................................ 23
1.14 Linac Area Quality Control ..................................................................................... 24
Section 2 – Patient Identification- Correct Patient, Correct Site, Correct Procedure ............. 24
2.1. Contraindications/Alerts ............................................................................................. 24
2.2. Sequence of Actions .................................................................................................... 24
2.2.1 STEP 1: Completed Consent Form .......................................................................... 24
2.2.2 STEP 2: Conducting Pre-Procedure Verification ................................................... 25
2.2.3 STEP 3: Marking the Site ....................................................................................... 25
2.2.4 STEP 4: Correct Site, Correct Procedure ................................................................ 25
Section 3 – Daily Linac Geometry Quality Assurance............................................................... 26
3.1 Linac 1, Linac 3 and Linac 4 Geometry QA and Imaging System Checks ....................... 26
3.1.1 Responsibilities ........................................................................................................ 26
3.1.2 Contraindications/Alerts: ........................................................................................ 27
3.1.3 Equipment & Materials ........................................................................................... 27
3.1.4 Sequence of Actions ................................................................................................ 28
3.2 Linac 2 Geometry QA and Imaging System Checks ........................................................ 35
3.2.1 Responsibilities ........................................................................................................ 35
3.2.2 Equipment & Materials ......................................................................................... 36
3.2.3 Sequence of Actions ................................................................................................ 37
Section 4 – Shutdown Procedures(WITHOUT OBI CAPABILITIES) ............................................ 41
4.1 Procedure ..................................................................................................................... 42
4.1.1 Inside the Bunker................................................................................................... 42
4.1.2 In the Control Room .............................................................................................. 42
4.2 LA1 Daily Machine Shutdown ....................................................................................... 43

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Section 5 – Pre-Treatment Quality Assurance Checks ............................................................. 45

5.1. Alerts............................................................................................................................ 46
5.2. Pre-Treatment Verification Task (V1) .......................................................................... 46
5.2.1 Create New Dynamic Document for the Pre-Treatment Verification .................... 46
5.2.2 Documents Management Section ........................................................................... 47
5.2.3 Treatment Plan Review ........................................................................................... 48
5.2.4 Treatment Sheet Review ......................................................................................... 48
5.2.5 Data Integrity Checks .............................................................................................. 49
5.2.6 Reference Point Section .......................................................................................... 51
5.2.7 Plan Scheduling ....................................................................................................... 52
5.2.8 Other ....................................................................................................................... 52
5.2.9 Creating a New Patient Alert................................................................................... 53
5.2.10 Signing off the Pre-Treatment Verification Check ................................................ 54
5.3 Completing the Post Initial Treatment QA (V2) ............................................................. 54
5.3.1 Approving the Treatment Verification Check Document ....................................... 56
Section 6 – Daily Machine Parameter Checks .......................................................................... 57
6.1 First Treatment Fraction ............................................................................................... 57
6.2 All subsequent treatment fractions ............................................................................. 57
Section 7 – Weekly Chart Checks ............................................................................................. 58
7.1 Alerts............................................................................................................................. 58
7.2 Initiating a Weekly Chart Check ................................................................................... 58
7.3 Review Dose ................................................................................................................. 59
7.4 Remaining Appointments............................................................................................... 59
7.5 Review Tasks ................................................................................................................. 60
7.6 Review Patient Notes/Journal Entries .......................................................................... 60
7.7 Delivered Treatment Parameters. ................................................................................ 61
7.8 Imaging Review. ........................................................................................................... 63
7.9 Other............................................................................................................................. 64
7.9.1 Document Review ................................................................................................... 64
7.9.2 Activity Capture Review ......................................................................................... 64
7.10 Completion of Encounter ........................................................................................... 65
7.10.1 QA’d ....................................................................................................................... 65
7.10.2 Journal Note .......................................................................................................... 65
7.10.3 New Patient Alerts ................................................................................................ 66

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7.10.4 Finalisation of the RT- Weekly Chart Check Encounter ........................................ 67

Section 8 – Course Completions, EBRT .................................................................................... 67
8.1 Initiating a Course completion check ........................................................................... 67
8.1.1 Treatment Sheet Check ......................................................................................... 67
8.1.2 Appointment/ Task Review ................................................................................... 68
8.1.3 Image Review ........................................................................................................ 68
8.1.4 RT EMR Data .......................................................................................................... 68
8.1.5 Other Items............................................................................................................ 69
8.2 Finalisation of encounter.............................................................................................. 70
Section 9 – Appointment Changes ........................................................................................... 70
9.1 Alerts .............................................................................................................................. 70
9.2 ARIA Read Only Workstation Set-up .............................................................................. 70
9.3 User Home – Linac Views ............................................................................................... 71
9.4 Linac Schedule ................................................................................................................ 72
9.5 Linac Tasks ...................................................................................................................... 72
9.6 Documentation............................................................................................................... 73
9.7 Patient Appointments .................................................................................................... 73
9.8 Patient Reviews .............................................................................................................. 74
9.9 Days End ......................................................................................................................... 75
Section 10 – On Treatment Reviews ........................................................................................ 75
10.1 Roles and Responsibilities ............................................................................................ 75
10.1.1 Nursing Staff .......................................................................................................... 75
10.1.2 Radiation Oncologists............................................................................................ 75
10.1.3 Radiation Therapists .............................................................................................. 75
10.2 Patient Check-In ........................................................................................................... 75
10.2.1 Patient Arrival........................................................................................................ 75
10.2.2 Completion of Appointment ................................................................................. 76
10.3 Patient Review.............................................................................................................. 76
10.3.1 Viewing the RO’s Review Appointments............................................................... 76
10.3.2 Reviewing the Patients .......................................................................................... 76
10.4 Linac Staff – Reviewing the RO Journal Note ............................................................... 79
Section 11 – RT Billing Procedures ........................................................................................... 82
11.1 Alerts ............................................................................................................................ 82
11.2 Daily Medicare Code Allocation Procedures (Radiation Therapists) ........................... 82

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11.3 Medicare Code Quality Assurance Checks .................................................................. 84

Section 12 – Monthly Accessory Equipment Condition Checks ............................................... 86
12.1 Alert .............................................................................................................................. 86
12.2 Procedure ..................................................................................................................... 86
Section 13 – Partial Treatments ............................................................................................... 90
13.1 Partial Treatment of a Plan .......................................................................................... 90
13.2 Partial Treatment of a Session ..................................................................................... 92
13.3 Appendix 1.................................................................................................................... 94
Section 14 – BrainLab Couch Transmission Correction............................................................ 94
14.1 Procedure ..................................................................................................................... 94
14.1.1 Treatment Staff ..................................................................................................... 94
14.1.2 Attenuation Factors............................................................................................... 95
14.1.3 ARIA: ...................................................................................................................... 95
14.2 Calculation Sheet for BrainLab couch top .................................................................... 97
Section 15 – DIBH- Treatment Technique ................................................................................ 97
15.1 Daily QA on the Linac for Treatment of DIBH Patients ................................................ 98
15.2 Preparing the RPM System........................................................................................... 98
15.3 Preparing the Bed for the Patient ................................................................................ 99
15.4 Setting Up the Patient .................................................................................................. 99
15.5 Setting Up the Patients DIBH on the RPM ................................................................. 101
15.6 Setting Up the Patient for Treatment ........................................................................ 101
15.7 Delivering the DIBH treatment................................................................................... 103
15.8 DIBH Trouble shooting technical issues ..................................................................... 103
16.8.1 Goggles not working: ....................................................................................... 103
16.8.2 Camera not tracking: ........................................................................................ 104
15.8.3 RPM session options incorrect: ........................................................................... 104
Appendix A ......................................................................................................................... 106
Appendix B Breast Setup Problem Solving ......................................................................... 107
Section 16 – Dosimetry Interlocks.......................................................................................... 109
16.1 Background ............................................................................................................... 109
16.2 Alerts......................................................................................................................... 109
16.3 Procedures ................................................................................................................ 110
Section 17 – Aria Tolerance Tables ........................................................................................ 112
17.1 Alert ............................................................................................................................ 112

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17.2 Aria Tolerance Tables ................................................................................................. 113

Related Policies, Standards, Procedures, Guidelines and Legislation.................................... 115
References .............................................................................................................................. 115
Definition of Terms................................................................................................................. 117
Search Terms .......................................................................................................................... 117

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Introduction
This manual describes the procedures and guidelines associated with the External Beam
Treatment Radiation Therapy using the Linear Accelerator.
Scope
This Manual applies to Radiation Therapists working within Radiation Oncology at the
Canberra Hospital.
Background
The clinical practice of megavoltage radiation therapy is complex and dynamic. Radiation
Therapists must have the appropriate qualifications and training to practice radiation
therapy in a safe, effective and efficient manner. The RT must exercise professional
judgement, skill and due care at all times.
The External Beam Radiation Therapy Operations Manual is a general guide for procedures
carried out in the Linear Accelerator section of Radiation Oncology, hereafter referred to as
LINAC.
Key Objectives
The key objective is the safe operation of the Radiation Therapy Service at the Canberra
Hospital.
Section 1 – Treatment Area General Information
1.1 Introduction
Each Radiation Therapist (RT) working on the LINAC is expected to:
 be familiar with LINAC Procedure Manual contents
 clarify any uncertainty with appropriately skilled staff related to equipment operation,
treatment instructions or image verification, prior to proceeding with treatment delivery
 follow all related procedures and policies described at:
o Radiation Oncology department level
o Capital Region Cancer Service level
o Health Directorate level

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Radiation Therapist's must also be familiar with the contents of Vendor supplied Manuals,
located in the LINAC Control Room. These manuals include, but are not limited to:
 Varian - CLINAC Instructions for Use Guide
 Varian - Treatment Delivery Instructions for Use Guide
 On Board Imager (OBI) Advanced Imaging Reference Guide
 ARIA Radiation Oncology Applications Manuals
The LINAC Procedure Manual will be revised annually by the Radiation Therapist 4.2 (Head of
Treatment) in consultation with LINAC Supervisors. However, in between such revisions any
changes in procedures will be communicated via:
 Distribution of hard copy memorandum to each work area (LINAC 1, LINAC 2, LINAC 3,
LINAC 4, Brachytherapy, SXRT, Planning, CT1, CT2)
 Each hard copy memorandum is to be filed in the respective LINAC Memorandum File
located in the LINAC Control Room. An electronic copy of the memorandum will be filed
in the Radiation Therapist Memo's Folder on the Radiation Oncology G Drive.
 Memoranda emailed to Radiation Therapists.
Upon commencing a rotation to the LINAC, each Radiation Therapist must familiarise or re-
familiarise themselves with the contents of the LINAC Procedure Manual and relevant
memoranda.
1.2 Radiation Therapists Staff Organisation
Head of Treatment
(RT 4.2)
Unit Supervisor
(RT 4.1)
Senior Radiation
Therapist (RT 3)
Radiation Radiation
Therapist (RT 2) Therapist (RT 2)
NPDP Radiation
Therapist (RT 1)
Under the current RT organisational structure, the Radiation Therapist 4.2, referred to locally
as Head of Treatment, is responsible for the overall management of the treatment service
related to LINAC 1, LINAC 2, LINAC 3, LINAC 4, Stereotactic Radiation Therapy, Brachytherapy
Treatment and Superficial X-Ray Therapy.
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The Head of Treatment is responsible for duties such as:

 the oversight of development associated with ARIA including account activation,
passwords, user rights and fault resolution
 the administration of essential treatment software/technology
 operational introduction of new equipment/technology
 quality improvement and quality assurance
 documentation of new protocols and procedures
 revision and update of existing protocols and procedures
 staff deployment including rostering, backfilling, annual leave and on call duty roster
 assistance with the development and implementation of contingency planning during
operational failures
 co-ordination of project groups
 active participation in project groups
 monitoring workflow, waiting times and workload within the treatment section
 other duties as delegated by the Deputy Chief or Chief Radiation Therapist
LINAC staffing normally comprises:

 one LINAC Supervisor (RT 4.1);
 one Senior RT (RT 3);
 two RT (RT 2) and;
 one Radiation Therapist Intern (RT 1) (provisionally accredited)
On days when staffing deviates from the four fully accredited person model outlined above
due to unplanned staff sick leave, the LINAC Supervisor or their delegate will inform the
Head of Treatment who will assess the need to provide an RT to backfill. Where possible,
Treatment RT's will be limited to working with three fully accredited team members for no
more than two consecutive days.
At the beginning of each day, the LINAC Supervisor will organise staff into one team of two
and one team of three (including the RT Intern). The ideal combination of staff in each team
will be one experienced RT and one less experienced RT (+/- Intern). The team combinations
will also take into account new case commencement, tea breaks and lunch breaks.
The LINAC Supervisor is responsible for duties including:

 maintaining efficient operation of LINAC
 maintenance of the safe and effective treatment delivery
 maintenance of clinical standards
 day to day operational organisation
 hands on clinical service delivery
 discharge of operational level administrative duties
 participation in quality assurance
 occupational health and safety
 risk identification and minimisation

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 delegation of duties
From time to time, the LINAC Supervisor will be required to perform other professional
duties resulting in their absence from the LINAC. In his/her absence, the RT3 and RT2's will
continue to ensure the safe, effective and efficient operation of the LINAC. During any
period of absence, the level of responsibility normally held by the LINAC Supervisor will
default to the RT3 working within the team.
1.3 Radiation Therapist Responsibilities

Both Accredited Radiation Therapists in the treatment team have equal, shared
responsibility, for ensuring the treatment is delivered according to the treatment
instructions.
Their routine duties as a team include, but are not limited to, undertaking:
 confirmation of patient identity and treatment site prior to treatment delivery
 accurate treatment set-up
 treatment delivery
 acquisition of imaging
 analysis of imaging
 continuous visual monitoring of the patient on CCTV
 accurate documentation and sign off to acknowledge treatment delivery
 update any written/electronic instructions/records
 determination of correct Medicare billing codes
 referral of patients to nursing/medical team for appropriate medical care
 restocking supplies
 administrative duties
 other duties as requested by the LINAC Supervisor
The RT who switches on the LINAC is responsible for activating the door interlocks upon exit
of the LINAC bunker and ensuring no other member of staff or public is within the LINAC.
1.4 Linac Start-up and Handover

The Medical Physics and Radiation Engineering (MPRE) Staff will complete the daily week
day start-up of LINAC and the On Board Imager (OBI). MPRE staff aim to handover LINAC for
Clinical Use approximately 30 minutes prior to the first scheduled treatment. When patient
caseload requires machine handover earlier than the usual handover time, the LINAC
Supervisor will liaise in advance with the Head of Treatment, who will assess the workload
and initiate appropriate action plans.
To indicate the successful completion of the LINAC start-up and OBI warm-up, the MPRE
Officer will tick the electron and photon modalities at the top of the Morning Geometry
Quality Assurance Log Book along with their signature and date.
If the Morning Geometry Quality Assurance Log Book has both radiation modalities ticked
and MPRE Officers initials, the RTs can assume the LINAC and OBI are safe for Clinical Use

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with no further checking, other than Geometry and OBI Quality Assurance, required from
the RT’s.
If the LINAC is in the ON condition1, but the refer to fault book box is ticked or MPRE
signature is missing from the appropriate section of the Morning Geometry Quality
Assurance Book, the RT must confirm with MPRE staff that the LINAC is ready for Clinical Use
prior to commencing clinical treatment.
It is departmental procedure, if for any reason, the MPRE Staff member does not want the
LINAC to be used, they will:
 record the relevant information in the LINAC Fault Book
 stick a yellow “OUT OF SERVICE" notice on the control console key of the machine
indicating that the machine is not to be used
 inform the LINAC Radiation Therapists personally (if present)
When the LINAC is handed over from MPRE, the Radiation Therapists must complete the
Daily Machine Geometry and OBI Quality Assurance Checks.
1.5 Daily Machine Geometry Quality Assurance

Prior to commencing clinical service delivery, one RT will complete Morning Geometry and
OBI Quality Assurance for LINAC according to the documented procedure contained in
Section 2 of the Radiation Therapy External Beam Operations Manual.
The RT who completes the Morning Geometry and OBI QA must sign the LINAC Daily
Geometry Quality Assurance Record and notify the LINAC Supervisor or their delegate of any
failure, which must be discussed with the MPRE Officer prior to proceeding with any clinical
treatment.
1.6 Treatment Delivery

 All patient treatments will be administered according to the documentation contained
on The Canberra Hospital Linear Accelerator Treatment Sheet. The treatment sheet
forms the primary source of treatment delivery information.
 Appointments for new cases are made by the Radiation Oncology Liaison Officer. Upon
commencing a course of treatment, the patient will be given a printed list of all
treatment appointments. If the patient has a special reason to ask for a change of
appointment, refer the patient to the LINAC Supervisor or their delegate. If the LINAC
Supervisor or their delegate is not available, leave a note so that the change can be
made to the booking.
1. When the LINAC is expected to be in the ON condition but is not, RE should be immediately informed. If unable to
contact RE, a Medical Physicist should be contacted.
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 The LINAC Supervisor is responsible for the maintenance and monitoring of LINAC
patient bookings. The LINAC Supervisor should:
o Adjust the patient bookings in between treating patients. The LINAC Supervisor
holds a large clinical service delivery responsibility and should not regularly utilise
large blocks of time for changing/adjusting patient appointments, completing
project work or responding to emails. Provisions for project work time are in place
and must be discussed in advance with the Head of Treatment.
o Make necessary adjustments to the time allotted for each patient. Patients may
require more or less time than originally allocated by the Radiation Oncology Liaison
Officer. The LINAC supervisor must adjust the allocated treatment time as necessary
to ensure the even distribution of patient load. Booking one patient over the top of
another patient must be avoided in all but exceptional circumstances as this will
impact on efficiency.
o Arrange staggered starts for staff at least one week in advance (where possible) as
required. In circumstances where less than one weeks’ notice is provided,
cooperation amongst the RT staff in determining shift rosters is required.
 All patients treated within the department will be checked in to ARIA and their name
will appear in the 4DTC Appointment Schedule.
 Inpatient treatment will be facilitated by the Wards pool service. The inpatient check
box must be ticked in ARIA to allow nursing staff to accurately organise the wards pool
service schedule in advance for the following day. Where possible, all Inpatient
treatments should be performed during core business hours so as ensure medical
and/or nursing cover. After hours, coverage should be arranged in advance with the
Ward Services Supervisor. The afterhours CNC may also be contacted through the
Switchboard if necessary.
1.6.1 Starting a New Case

In order to maintain safety and efficiency, the number of new cases, including new courses
of treatment, phase 2, boosts and technique changes, is ordinarily limited to six per day. This
limit may be exceeded at the discretion of the LINAC Supervisor following discussion with
the Radiation Oncology Liaison Officer.
Details of the procedure for commencing a new case are found in Section 5 of the External
Beam Operations Manual.
1.6.2 Team Work Guidelines

One team is usually in the LINAC Bunker treating a patient whilst the other is outside
performing administrative tasks and preparing for the next patient(s).
The team outside the treatment bunker should be completing tasks such as:
 Collating upcoming patients’ treatment sheets personal accessory equipment.
 Monitoring patient reviews.
 Entering and checking data integrity in ARIA (V1 and V2 Checks)
 Reviewing EPI, kV and CBCT Images.
 Restocking Supplies.
 Perform Weekly Treatment Sheet QA, locally referred to as chart checks

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 Escorting next patient to the LINAC Bunker entrance as the previous patient treatment
nears completion. Do not bring the patient to the bunker entrance too soon as there is
no suitable seating.
 Ensure the next patient is fully prepared for with any pre-treatment prerequisites, e.g.
Full/empty bladder, premed etc
 Organising patient from the ward with or without prior medication in advance ensuring
that others are aware it has been done.
 During quiet periods the LINAC Supervisor may delegate cleaning, stock replenishment,
quality assurance or administrative tasks to any member of the team.
1.6.3 Notes on Patient Set-Ups

 The RT who enters the room first will commence freeing the previous patient from
immobilisation devices and lower the couch to facilitate unloading. The other member
of the team will begin preparation for the next patient.
 As one patient leaves the LINAC Bunker, the next patient enters. The treating RT team
will position the patient on the treatment couch according to documented treatment
set-up instructions.
 One RT will raise the treatment couch and maintain bed controls whilst the other RT
assumes responsibility for straightening and levelling the patient and ultimately turning
on the machine.
 The documented treatment setup instructions must always be taken into the LINAC
Bunker to set up the patient. The treatment sheet is regarded as the primary source of
patient treatment information. Any discrepancies between the Treatment Sheet, ARIA
Data or patient set up must be clarified prior to proceeding with treatment.
 Two Accredited RTs must be present for each weekday patient treatment. All
Provisionally Accredited RT, such as Interns, must always be countersigned.
 The RED Lasers correspond with the LINAC Isocentre. Green Lasers are to be used for
patient levelling only.
 After patient setup and prior to leaving the LINAC Bunker, the RT who will switch on the
LINAC, should clearly call out important details, set-up details and some geometric
parameters. These details can be found in Section 6 of the External Beam Operations
Manual.
 The second RT shall cross check the set-up details against the LINAC.
 All measurements are entered in cm and angles in degrees. The field size in the direction
of the long axis of patient will be entered with a suffix "L", e.g. 16 L.
 The RT who switches on the LINAC must be the last person to exit the LINAC Bunker
prior to delivering the planned treatment. This RT is responsible for ensuring that the
only person in the bunker, prior to arming the door interlock, is the patient
 The RT seated at the ARIA 4DTC workstation will read aloud all out of tolerance
parameters that require an Override and acknowledge the interlock. Then, MU, energy
and wedge must be checked from the treatment sheet against ARIA 4DTC work station
and LINAC computer before enabling Beam On. This helps preventing mismatch in MU if
there is a modification from planning and ensures patient having correct accessory such
as bolus or block shielding on.

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 On the first treatment, the responsible RT is required to read out all the beam
parameters as well as wedge orientation from the treatment sheet and check against
the LINAC computer while the other RT cross checks on ARIA 4DTC.
 Before switching the beam on, also check the box on the treatment sheet where the
current day's MU will be recorded, as there may be a modification from planning.
 Radiation Therapists must keep a close watch of the patient via the CCTV and ensure
that the audio intercom is switched on during every treatment.
IMPORTANT: The treatment RTs are not to be interrupted or distracted by other team
members during treatment delivery. During rotation of the gantry from outside the room,
the Responsible RT must monitor the CCTV to ensure collision is avoided.
The Radiation Therapist switching on the LINAC will:

 Accurately record the treatment details in the treatment sheet
 Check that the MU's shown in the treatment sheet have been correctly delivered. A
Normal Treatment Complete' message will confirm this.
 Check if routine imaging or pre imaging is required
 Ensure FSD/contour checks are completed
 Fulfil request by Dr or fellow RT, such as TLD, take measurements, electron mock-up.
The Radiation Therapist seated at the 4DTC will:

 Assign the Medicare Billing Codes as per the described procedure
 On releasing the patient, ensure the patient is fit and has means of transport to go
home.
 If the patient is from the ward, ensure the Radiation Oncology Porter takes the patient
back.
 Check if the patient needs to see a doctor on review day, or nursing staff for other
health/treatment reasons.
1.6.4 Billing Procedures

 Medicare billing codes will be assigned using Activity Capture module within ARIA. The
specific procedures are detailed in the ARIA Operation Manual, Section 1.3 Radiation
Therapist Medicare Code Assignment and Quality Assurance.
 At the commencement of each course of treatment (including technique changes,
boosts and subsequent phases), the RT undertaking the ARIA Data Integrity Checks will
confirm the accuracy of the Medicare Billing Codes, including code suffixes for new or
subsequent treatment courses.
 On a weekly basis, all billing codes recorded in ARIA Activity Capture will be checked for
accuracy. Where the codes entered in ARIA are not believed to be correct, the RT must
correct the codes prior to reviewing them. The procedure associated with RT
component of Quality Assurance of Radiation Oncology Billing Codes is in Section 11
1.6.5 Verification Images

 The guidelines for acquisition and assessment of verification images can be found in
Section 13 of the External Beam Operations Manual.

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 Images are to be reviewed throughout the day prior to the delivery of the next
treatment fraction.
 Two accredited RT's must review all offline images. The results need to be noted in ARIA
and confirmed prior the following treatment.
 Two accredited RT's must review all Online Images. One accredited RT is required to
perform a retrospective, offline assessment of the online match.
 All changes to a treatment arising from a reviewed image are to be clearly documented
in the Treatment Sheet by the RT observing the change at the image review. A second
RT must countersign any change to indicate their agreement with magnitude and
direction
 Images must be made available for the Radiation Oncologist to review.
1.6.6 Weekly Chart Checks

 The weekly chart check Procedure can be found in Section 7 of the External Beam
Operations Manual
 Weekly Chart Checks are to be undertaken on all patients receiving a course of
treatment as part of routine quality assurance. The Weekly Chart Checks are an
important validation of the correspondence of the data contained within the Treatment
Sheet and the Record & Verify System.
 The LINAC Supervisor will ensure weekly chart checks are completed by all members of
the treatment team.
 RT's are to update minor changes detected in the Weekly Chart Checks in ARIA. Any
change that indicates a dosimetry problem must be immediately raised with the LINAC
Supervisor and the Responsible Planner prior to delivering any further treatment.
1.6.7 Patient Reviews

 Patients are reviewed by Radiation Oncologists and Nurses according to a
predetermined schedule posted at each LINAC.
 Treatment folders of patients for review are to be placed in the review tray on the
nurses' desk as per the Review Schedule.
 Upon collecting treatment folders of patients that have been reviewed by the Radiation
Oncologist, the Radiation Therapist will read the Radiation Oncologist's remarks entered
under Journal in ARIA.
 The Radiation Therapist will ensure any instructions are carried out and then write a
note in the treatment sheet indicating the date the patient was seen, who saw the
patient and sign the "Action By" column so that other Radiation Therapist's do not have
to follow them up again. i.e. 12/06/2015 Seen by Dr Austen....... RTs sig.
 If the action is expected of other staff groups e.g. nurses/social worker/dietician etc.,
check that the relevant staff has, or is going to take the action, and note this when
signing in the "Action By " column i.e. "to be carried out by _______(nurse/social
worker/dietician etc.,)". If applicable, enter any actions necessary in pencil at the
appropriate place in the treatment sheet and create a patient alert in ARIA.
 The Radiation Therapist signing for and/or following up on the Radiation Oncologist's
instruction is responsible for creating an occasion of service for the review clinic, and
then discharging the patient with the correct Medicare code.

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1.6.8 Course Completions

The External Beam Radiation Therapy Course Completions Procedure can be found in
Section 8 of the External Beam Operations Manual
 Upon completing a course of treatment, the RT must direct the patient to the Nurses to
arrange a follow-up appointment. Upon doing this, the RT must sign the relevant section
of the treatment sheet.
 If the Radiation Oncologist does not want a follow-up appointment to be made, write
this on the treatment sheet. Put the treatment record aside for the final treatment
check.
 For finished cases, RT's will do a final check of the treatment sheet before the treatment
sheet leaves the Treatment Unit. Any accredited RT may perform the final check.
 Final Checks must be completed no later than two days after the course completion.
Under no circumstances should final checks be stockpiled as this has an impact on
workflow for other areas within the Radiation Oncology Department.
1.6.9 Close of Business

At close of business, Radiation Therapists must:-
 Ensure that the current days work has been completed.
 Record any down time in the fault book and ensure that down time is reflected in ARIA
using the Maintenance Activity Category and the Planned/Unplanned downtime
activities.
 Clean and tidy the treatment room; change the linen; replenish the linen; turn off fans;
leave the Treatment Room lights on; turn off music & store IPods
 Disable the neutron door mechanics (LA3 and LA4 only).
 Shutdown all equipment by following the relevant Linac Shutdown Procedure see
Section 4 of the External Beam Operations Manual
 Put away all treatment folders and case histories.
 Lock up the LINAC keys and console room if applicable.
 Ensure that all patients have left the department safely.
1. 6.10 Quality Assurance

 The Quality Control of the Accessory Equipment for the Varian iX Linear Accelerator is
done monthly by the LINAC Supervisor or their delegate, see Section 19 of the External
Beam Operations Manual
 There is a task scheduled monthly to remind staff of this activity, this task should be
completed by the staff member undertaking the equipment audit.
1.6.11 Personal Stabilisation Devices

 Equipment Storage:
o At no time should personal stabilisation devices such as Thermoplastic shells and
Accuform headrests be placed on the floor for storage
o No patient equipment should be kept outside the linac control room during or after
business hours.
o At the commencement of the day, please ensure all treatment files and patient
equipment are accounted for and available at the correct Linac. For transfer

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between Linacs, all shells should be transported directly from bunker to bunker. If a
trolley is required for transport or additional storage, this should be stored within
the bunker only.
o If a patient has been identified as contracting an infectious condition, all patients
treatment equipment will now be placed inside a linen bag.
 No yellow or clear garbage bags are to be used. This is to eliminate any
misunderstandings and to isolate the patients equipment from others shells. The
bag should be clearly tagged and identified with the patient’s information.
 Please continue to use universal precautions when handling these bags.
 Equipment Disposal:
For details of equipment disposal at the completion of a course of treatment see Section
8 of the External Beam Operations Manual.
1.6.12 Other Matters

 Combined Ward Round is on Tuesday from 8:00am, therefore no ward patients should
be brought down at this time.
 For patients having chemotherapy:
o Liaise with the Radiation Oncology Treatment Area Nurse to ensure timely
treatment delivery
o If possible, the patients’ treatment appointments should be annotated to reflect
days when concurrent chemotherapy is scheduled.
o A spill kit will usually accompany the patient from the ward and into the treatment
room.
 Ensure the treatment room is stocked with medical supplies.
 LA4 staff: responsible for changing all patient Gowns weekly;
 LA4 staff: responsible for SXRT patient scheduling and warm-up and treatment
1.7 Annual Business

 In October-November, the Head of Treatment Radiation Therapist will create diary
pages for the coming year in ARIA and CAS.
 At the end of each calendar year, the Head of Treatment will perform the following
Quality Assurance checks on 20 randomly selected patients to determine the
compliance with departmental policies
o Imaging Frequency
o Machine QA
o Image match results
o Equipment condition reports
o Weekly Chart Checks
o FSD checks
o ARIA Entry
1.8 Fault Documentation

Radiation Therapists when logging a fault must complete the white section at the top of the
fault book page. Radiation Therapists must use their professional judgement when

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determining the implications of machinery and equipment faults and failures and whether a
fault will prevent the progression of treatment.
As a rule, all faults and interlocks must be recorded in the LINAC Logbook. It is essential that
information in relation to the machine parameters such as gantry, collimator, couch and
energy are recorded to determine whether there is a consistency in fault or trends.
All logged faults must have the clinical release or referral to MPRE section completed. The
following summarises the expectations of all Radiation Therapist if they are releasing a linac
back into clinical use:
 Linacs can only be released for clinical use by fully accredited Radiation Therapists (Level
2.1 or greater)
 Only minor faults not preventing the progression of treatment or Dosimetry Interlocks
described in Section 18 of the External Beam Operations Manual should be released by
Radiation Therapist, all other faults should be referred to MPRE
 Dosimetry interlocks can be cleared according to the Dosimetry Interlocks Standard
Operating Procedure. Staff need to make themselves familiar with the limitations,
documentation requirements and alerts specified in this protocol.
 All hardware/software/other faults must be recorded in the fault book. If an accredited
Radiation Therapist using professional judgement feels this fault is able to be cleared
and will not affect the safe delivery of treatment they may release the machine back
into clinical use by signing this section.
 If a staff member is not confident making the decision to release the linac for clinical
use, the linac senior or Head of Treatment should be consulted if available. If these staff
members are not available or unable to safely resolve the issue Medical Physics and
Radiation Engineering (MPRE) staff must be consulted prior to treatment resuming.
 If a staff member releases a linac for clinical use, they are responsible for notifying the
linac senior of this fault in a timely manner. This is to enable recurring faults and/or
patterns of faults to be communicated to the Head of Treatment and MPRE, and the
liaising of requirements and time frames for repairs.
In the event that the RE officer is not contactable, Radiation Therapists are to contact a
Medical Physicist on duty or the Chief Medical Physicist by Mobile phone.
1.8.1 LINAC Faults preventing the progression of treatment

 If the LINAC Console indicates a fault that prevents the continuation of treatment, notify
RE Officer immediately via telephone and document the fault in the LINAC Fault Book.
 One Radiation Therapist remains at the treatment console and the other treating
Radiation Therapist enters the LINAC Bunker to notify and monitor the patient.
 The Radiation Therapist outside the LINAC Bunker will liaise with the RE Officer as to
whether the patient needs to be removed from the LINAC Bunker.
 When the fault is cleared, the RE Officer will advise of any necessary action required by
the RT in order to recommence treatment and make their notation in the LINAC Fault
Book.

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1.8.2 LINAC Faults not preventing the progression of treatment

 Documented faults that do not halt the progression of treatment are usually addressed
by RE during the scheduled machine maintenance days.
 If the LINAC indicates a fault that does not require the intervention of an RE Officer it
must be documented in the Fault Book. If the fault persists, RE must be notified via
telephone.
1.8.3 Faulty Accessory Equipment

 All details of faulty equipment, detected through general observation or during the
scheduled Monthly Accessory Equipment Condition Checks procedure described in
Section 12 of the External Beam Operations Manual, must be discussed with the LINAC
Supervisor, who will either arrange repair, or render the equipment temporarily out of
service.
 Requests for replacement of faulty or ageing equipment must be made via email to the
Head of Treatment.
1.9 Machine Breakdowns

Points to remember in case of a machine breakdown:
 Release the patient from the treatment couch immediately if the breakdown is major.
 As a safety precaution, ensure that patients or any other people (patient's relatives,
wards man, nurses, etc.) leave the treatment room.
IMPORTANT*
The mechanical counter is affected if the "FIXED" or "READY/COMPLETE" console buttons
are pushed. Therefore, DO NOT push any buttons until the mechanical counter value has
been recorded.
If the breakdown occurs during a treatment, then:

 Record the number of MU's already delivered and the event in the "Planning Notes"
column, inside the treatment sheet. (e.g. "______MU delivered when machine
breakdown occurred")
 Calculate the number of MU left untreated at the console and enter this number, in
pencil, for the correct field, inside the treatment sheet.
 Call the RE staff and hand over the machine.
 Ensure the fault is clearly and accurately recorded in the LINAC iX Fault Book.
 To avoid confusion, the LINAC Supervisor will contact the Head of Treatment and both
will co-ordinate the patient management after the breakdown.
In general:
 the patients currently waiting in the department for treatment will be informed of the
situation and will be asked to either wait, or go away and to call the LINAC in about one
hours time.

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 patients due for treatment in the next hour will be contacted by phone, informed of the
situation, asked to hold off coming in for treatment and to call the LINAC in about one
hour’s time.
 the patient’s decision and any details will be recorded on the front of the treatment
folder.
 If a patient is transferred from LINAC 1 to LINAC 2 or 3, no recalculation of the plan is
required as the machines have been beam matched.
 If a patient is transferred to LINAC 4, care should be taken to ensure the difference in
the BrainLab couch top is not dosimetrically significant. If in doubt, discuss with Head of
Planning. Patients with posterior or oblique fields may be transferred to LA4 in
emergency circumstances only, refer to section 23 of the External Beam Operations
Manual.
 If treatment is to recommence, the Head of Treatment will judge if the full day’s
workload can be treated up to 7pm. If not the Head of Treatment will estimate the
number of patients that can be treated in the remaining time (up to 7pm) and obtain a
patient priority list from each Radiation Oncologist for the available treatment time
slots. Staff will be required to work overtime as necessary.
 The LINAC Supervisor will:
o Produce a revised treatment appointment list (either from the Appointment Booking
System or hand written).
o Inform patients of their revised appointment times/the departmental response.
o Redistribute patients and staff to other LINACs
o Notify the ward. If ward patients are coming late.
 The Head of Treatment will:

o Work with the LINAC supervisor to co-ordinate the response
o Notify all other staff groups of the plan of action
o Liaise with Ward Services (if required)
o Notify Assistant Director Facilities Management Services (page through switch), and
Security, of altered start and finish times, so that patients are able to enter the
Department via the main departmental doors.
o Provide details to the DCRT for wider communication
o If the repair is likely to be prolonged, the Head of Treatment will work with the
Deputy Chief Radiation Therapist, the Radiation Oncologist's and Head of Planning to
sort out the Departmental response (e.g. suspend treatment while repair is
underway).
 When the LINAC becomes available for Clinical Service, RE are to hand the LINAC over as
per the morning handover and the Daily Machine Geometry Quality Control check is to
be repeated.
 At the end of the treatment day ensure:
o all patients are notified of arrangements for the next day
o all treatment sheets have been documented correctly including notation that
patient treatment was cancelled due to equipment failure
o all patients have left the Department safely

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 The LINAC Supervisor will update the appointments as required, i.e. change patient
finishing dates if patients have been cancelled and as necessary relay these changes to
other LINACs.
 The LINAC Unit Supervisor will provide a shift roster for staff on LINAC for all
breakdowns beyond one day. At least one RT3.1 or above will be required to work a late
shift.
1.10 Transport from Wards, Hospitals & Community

Radiation Oncology Porter
 Hospital residence and Inpatient transport will be facilitated by the Wards pool service.
The schedule will be organised by nursing staff in advance, prior to the following
treatment day.
 Radiation Therapist’s should ensure that any known inpatients have the inpatient check
box tick in ARIA to enable nursing staff to readily identify inpatient status.
 Outpatients are responsible for their own transport. Nevertheless if an outpatient has
problems with transport, contact the Social Worker who may be able to help with
booking community transport. On certain occasions, taxi vouchers may be available
from the nurses.
Community Transport
 Community Transport is usually organised by the Radiation Oncology Liaison Officer or
Social Worker.
Inpatients at Other Hospitals

 For patients who are inpatients at other hospitals that are having a consecutive course
of treatment, give the patient/nurse attendant a printed Appointment List so that the
nurse(s) in charge of the patient at the associated hospital can arrange the patients
transport. This must include any weekend appointments.
 Patients transferred to Radiation Oncology by Ambulance are to be treated in a morning
appointment slot where possible.
 Ambulance patients should be treated as a high priority immediately or very soon after
their arrival.
 For patients who have come from another hospital by ambulance let the Radiation
Oncology nurses know when the patient has completed treatment so that they can
arrange the return transport.
1.11 Safety
 Safety Procedures are to be strictly adhered to.
 Points concerning safety listed in the following are by no means exhaustive. Every RT is
expected to exercise due care at all times to ensure the safety of patients, of
himself/herself, of his/her colleagues, and of the public.
 "At all times act in such a way as to .... ensure that by no action or omission on his/her
part their (patients') condition or safety is placed at risk. ....Have regard to the physical
working conditions and make known to the appropriate authority if these endanger safe
standards of practice in any way." Quoted from "A Code of Professional Conduct for
Radiographers" by the College of Radiographers. Radiography Sep/Oct 1985 Vol 51 NO

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599 p286.
1.11.1 General Safety

 Observe all safe practices for lifting heavy objects including patients. See Radiation
Oncology Manual Handling Procedures found in Section 1.3 of the Radiation Therapist
Operations Manual
 Whenever necessary, use the PATSLIDE, MEDILIFT, Lifting Equipment or Slide Sheet for
patients who are not ambulant or have disease/injuries of the spinal column. For more
details related to Manual Handling refer to Radiation Oncology Manual Handling
Procedure
 Be conscientious about radiation hazards to patients, staff, visitors and the public.
Radiation protection is a joint effort/responsibility of all RT's.
 Do not enter/remain in the treatment room when the beam is on.
 Do not stand at the entry to the maze while the beam is on.
 Do not switch the beam on if any person (except a patient who is being treated) is in the
treatment room.
 Similar precautions should be taken for non-patient work: only the last person to leave
the treatment room should activate the door interlock.
 During work hours, the treatment room is a Controlled Area. For radiation protection
and operational safety, effectiveness and efficiency, only authorised staff or persons
under their supervision have access to the treatment room and the console area.
Patient's relatives and friends generally do not have access to these areas except for
special situations such as the need for them to act as interpreters. (Patients privacy also
needs to be protected).
 Never leave equipment unattended while operating (Beam On), or in an active state
where accidental irradiation is possible.
 Whenever the machine is unattended, place the machine in Standby, remove the LINAC
keys from the console and place them under the CLINAC keyboard.
 Radiation Therapist’s operating the treatment machine must not be disturbed whilst
delivering a patients treatment.
1.11.2 Shielding Blocks Safety

Shielding blocks are rarely used. However, the following safety procedures relating to
shielding blocks must be observed:
 Gloves should be worn when handling LMA blocks
 For light beam modification devices such as small shielding blocks, wedges,
compensators, etc., the only practical measure for safety is to avoid moving such objects
across the patient.
 Ensure that no blocks are on the shadow-tray before moving the gantry.
 Segmented blocks are always to be carried separately.
 For heavy shielding blocks that are positioned over the patient, including the lung blocks
for mantle fields, large blocks for inverted-Y fields, half-field blocks, blocks for the Ant
oblique SCF field, etc., the following procedure must be used:
o Without using the shielding blocks, set up the patient in the treatment position first,
according to the field centre, borders, SSD, etc.

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o Slide the treatment couch away from the tube head so that the whole of the patient
(including the patient's head) is outside the area which is vertically underneath the
shadow tray.
o Insert the appropriate shadow tray plate and put the shielding blocks on to the
template which has already been aligned to the centre cross of the plate and taped
to the plate.
o After the shielding blocks are aligned in position, slide the couch back to the position
underneath the tube head.
o Check that the field centre and borders are still correct according to the light field.
o After the treatment of the field, again slide the couch out before removing the
shielding blocks from the tray.
 Be conscientious about patient/staff safety when moving equipment, whether manually
or by electric device.
 Be conscientious about safeguards in working with low-melting-point alloy. In particular,
o Keep the work area clean and prohibit eating and drinking in the work area.
o Wash hands with soap and cold water after each work session to prevent ingestion
or absorption of the toxic metals.
o Never dispose of the alloy yourself. Return any unrequired alloy to the mould room.
Do not allow public access to alloy.
1.12 Accident & Incidents

 Accident/incident reports must be filled IMMEDIATELY after an accident/incident by all
staff involved.
 The correct means of reporting an incident/accident involving a patient or visitor is via
the Riskman Portal on the ACT Health Intranet.
 In case of an accident involving a patient or visitor, please ensure that the patient or
visitor is seen by a doctor as soon as possible before the patient/visitor leaves the
Department, even if the patient/visitor is not keen to see a doctor. A patient should be
seen by the doctor in charge of his/her case, or by the Registrar. (If neither is available,
see the doctor at the Accident and Emergency Department.) A visitor should be seen by
a doctor at the Accident and Emergency Department. If the patient/visitor insists on not
seeing a doctor, or going away to see his/her own doctor, record this in the report.
 If the accident involves a staff member, for the well-being of him/her and for possible
future needs of workers compensation claim, the staff member should see the staff
doctor or the doctor at the Accident and Emergency Department.
 If there is a Radiation Accident, this must be reported to the Deputy Chief Radiation
Therapist, the Chief Radiation Therapist and the Chief Medical Physicist. A "RADIATION
INCIDENT STATEMENT" form must be filled in as well as a Riskman Report.
 If there is a Radiation Therapy incident involving a patient's treatment, an electronic
"RADIATION THERAPY INCIDENT REPORT" must be filled in by all staff involved and then
reported to the Head of Treatment, Head of Planning and the Deputy Chief Radiation
Therapist. A Riskman Report must also be completed on the ACT Health Intranet.
1.13 Loss/Theft/Property Damage

If there is a theft/loss of property belonging to either staff, patient, contact the Deputy Chief
Radiation Therapist to report the theft and collect the appropriate forms.
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1.14 Linac Area Quality Control

Quality Control Procedures performed by RT’s required for the LINAC Treatment Unit
include:
 Daily Geometry Quality Control for the iX Linear Accelerator
 ARIA Entry Validation Checks and V2
 Monthly Quality Control of Accessory Equipment Condition for the Varian iX Linear
Accelerator
 Weekly Chart Checks for all patients undergoing a course of Radiation Therapy
Treatment.
 Course completion checks at the completion of a course of Radiation Therapy
Treatment.
Back to Table of Contents
Section 2 – Patient Identification- Correct Patient, Correct Site, Correct Procedure
The following steps that must be undertaken to ensure the correct patient, correct site and
the correct procedure for patients receiving treatment in the Radiation Oncology
department.
2.1. Contraindications/Alerts
 Do not proceed with treatment delivery until all pre-procedure documentation is
accurate and complete.
 For patients who are transferred from locations within the hospital who are incapable of
personally participating in the verification process, and with no authorised
representative present, a member of staff from the preceding location must act as the
patient’s representative for the verification.
 If a discrepancy arises at any point during the Correct Patient, Correct Site, Correct
Procedure verification, the procedure will not commence until the discrepancy is
resolved. All team members must agree on the resolution of the discrepancy. If
disagreement continues to occur then the Radiation Oncologist in charge of the
treatment carries ultimate responsibility for the care of the patient and should decide
the most appropriate course of action.
 When a patient refuses skin marking or tattoos, documentation must be recorded in the
treatment record.
2.2. Sequence of Actions

2.2.1 STEP 1: Completed Consent Form
Prior to the delivery of radiation treatment, the Patient must have completed Consent for
Radiation Treatment Form (Form Number 15425). The Consent for Radiation Treatment
form must contain:
 Patient name
 Date of Birth
 Medical Record Number

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 Patient/Parent/Guardian/Power of Attorney signature

 Radiation Oncologist Signature
2.2.2 STEP 2: Conducting Pre-Procedure Verification

Prior to a new course of Radiation Therapy commencing, the treatment sheet, clinical notes
and treatment plan should be reviewed and cross-checked against ARIA Data to ensure all
parameters are correct for the proposed treatment.
All documentation must be appropriately labelled and oriented.
Correct Patient
The Radiation Therapist (RT) who will switch on the Linear Accelerator shall check the
patient’s identification, patient identification photo (if available), full name, address, date of
birth and armband to confirm the correct patient.
The RT must always ensure the correct patient by asking the patient to state their name and
date of birth.
Verification of the correct patient must occur upon entry to the linear accelerator bunker or
as soon as practicable after entering the linear accelerator bunker. Aim to avoid correct
patient verification immediately before leaving the bunker as patient movement has been
observed and treatment accuracy may be compromised. If correct patient verification is
overlooked until the patient is in the set-up position, isocentre positioning must be carefully
re-checked prior to delivering the radiation therapy treatment to ensure the patient has not
moved.
2.2.3 STEP 3: Marking the Site

The reference tattoo/isocentre will be identified and marked daily with semipermanent
marker, as indicated by the Patient Treatment Sheet.
2.2.4 STEP 4: Correct Site, Correct Procedure

The correct treatment sheet is to be inside the Linac Bunker when setting up each patient.
Prior to leaving the Linac Bunker, the RT who will switch on the Linear Accelerator must
verbally state the setup parameters including:
 patient name
 anatomic site being irradiated with particular attention to left/right
 isocentre location in relation to standard anatomic position
 other key treatment information
For example: “John Jones on the bed, treating a left hip, isocentre is 10cm left of anterior
midline, anterior field 10 x 10cm, no MLC”
The second Radiation Therapist present shall check these instructions and parameters on the
Clinac NOT ARIA.

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The treatment is correctly monitored and recorded as per departmental guidelines.
Section 3 – Daily Linac Geometry Quality Assurance
3.1 Linac 1, Linac 3 and Linac 4 Geometry QA and Imaging System Checks
Daily Linear Accelerator (Linac) Geometric Quality Assurance checks must be performed
each morning prior to commencement of treatment delivery and following the repair of
equipment to ensure operation within accepted tolerances. It is to be undertaken by an
accredited Radiation Therapist.
The aims of the Daily Linac Geometry Quality Assurance checks are to ensure:
 correct daily handover procedures are observed prior to treatment delivery
 Linac geometry meets acceptable limits
 the simulated treatment geometry can be accurately reproduced on a daily basis at the
Linac
Critical features of the Geometry Check are:

 Accuracy of the Optical Field Dimension
 Accuracy of the Collimator Angle
 Accuracy of the Gantry Angle
 Correlation of the Mechanical Isocentre of the Gantry with the 100cm reading on the
Optical Distance Indicator (ODI)
 Correlation of the Optical Laser System (red) with the beam isocentre
 Parallelism of the patient positioning/set-up laser system (green) with isocentric lateral
lasers (red)
 Correlation of longitudinal, lateral and vertical physical couch motion with the Digital
Couch Readout
 On Board Imaging (OBI) operation and accuracy
Success is entered on the chart as a tick (√). Failure is entered as a cross (x). This assumes
IEC1217 scales for all machine mechanical parameters.
3.1.1 Responsibilities
3.1.1.1 Radiation Engineering (RE) & Medical Physics (MP) Staff
Prior to the daily release/handover of the Linear Accelerator, the RE or MP staff will perform
morning run-up to ensure the Linac is free from faults and dose output, for all beam
energies, and is within acceptable limits.
The success of the daily dose output checks will be recorded by the RE or MP staff member
on the Linac Daily Geometry Quality Assurance Record. In the absence of ticking, refer to
fault book box the RE or MP staff member is signing to denote the Linear Accelerator is fit
for clinical use.
3.1.1.2 Radiation Therapist (RT)

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When the Linac is handed over from RE or MP, the Radiation Therapists must complete the
Daily Machine Geometry Checks to determine the accuracy of the treatment geometry
system.
The following documentation contains procedural instruction and the current acceptable
limits for daily geometric quality assurance checks.
If any geometry of functionality failures are detected during this process, the RT staff must
contact the RE or MP staff to have the issues rectified prior to clinical use. RT staff are
required to log any failures in the Linac Log/Fault Book. RT staffs are only to take
responsibility for the Linac after notation is dated and recorded in the Linac Log/Fault Book,
from either RE or MP, stating the Linac is “Fit for Clinical Use”
3.1.2 Contraindications/Alerts:
If the RE or MP section of the chart is not completed, RE or MP staff must be contacted prior
to commencement of clinical treatment.
If any failures in the Daily Geometry QA are detected, RE or MP staff must be contacted to
make any required adjustments prior to clinical use.
If any RE or MP Staff member does not want the Linac to be used clinically, they will:
 Tick the refer to fault book box on the chart.
 record the relevant information in the ‘Linac Fault Book'
 place a yellow ‘OUT OF SERVICE” notice on the control console key of the Linac
indicating that the machine is not to be used inform the Radiation Therapists personally
(if present)
3.1.3 Equipment & Materials

The following equipment is required to successfully perform the Daily Linac Geometry
Quality Assurance checks:
1. Linac Log/Fault Book
2. Iso-Align Geometry Jig
3. Lok-Bar
4. Spirit Level
5. Front Pointer and Mount
6. OBI QA cube
7. Linac Daily Geometry Quality Assurance Record (hereafter referred to as the “chart”)

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Figure 1: Iso-Align Geometry Jig
3.1.4 Sequence of Actions

3.1.4.1 PART 1: Dose Output Check
1. Check the chart for the current day; identify the RE or MP staff’s entry and signature
indicating Dose Output Checks have been performed.
2. If the refer to fault book box has been ticked, the fault book must be referred to and the
released for clinical use box MUST be ticked prior to the commencement of clinical
treatment.
3.1.4.2 PART 2: Linac Geometry Accuracy Check

CRITERIA:
The criteria for the success or failure when testing each parameter are based on the
manufacturer’s specifications or, in the absence of manufacturer’s specifications, on the
advice of the Senior Radiation Oncology Medical Physicist (ROMP).
Success is entered on the chart as a tick (√). Failure is entered as a cross (x) with a comment
to describe the nature and extent of the variation e.g. (x) 3mm sup.
All failures are to be discussed with RE or MP staff and entered in the Linac Fault/Log Book
found in the Linac Control Room.
PROCEDURE: 2
a) Digital Couch Vertical Readout Correspondence.
The limit for variation of the digital couch vertical readout is +/-0.2cm.
This part of the procedure does not require the Iso-Align Jig

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1. Using the ODI set 100cm FSD to surface of the solid carbon fibre couch top.
2. Ensure digital couch vertical readout equals 0 (+/-0.2cm).
3. Enter success or failure on the chart.
b) ODI/Mechanical Isocentre Verification

Limit = +/- 0.2cm1
1. Place the Iso-Align Baseplate on the Linac couch top.
2. Using the spirit level ensure the Iso-Align Baseplate is level in both planes. Adjust the
levelling feet as necessary.
3. Align the Linac Crosshairs with the Iso-Align Baseplate Crosshairs
4. Carefully insert the Iso-Align Faceplate into the Iso-Align Baseplate. Secure the
faceplate to baseplate with retaining clamps and knurl screws
5. Rotate the Iso-Align Faceplate to the horizontal plane and lock into place using the
side mount locking mechanism.
6. Do not move the Iso-Align Jig until instructed
7. Attach the mechanical front pointer mechanism to the collimator.
8. Insert the front pointer and adjust to the 100cm marking
9. Adjust the couch vertical until the tip of the mechanical front pointer touches the
surface of the Iso-Align Base Plate
10. Remove the mechanical front pointer and front pointer mechanism
11. Switch on the ODI and check that the Digital Readout equals 100cm
12. Check the horizontal lasers skim the surface of Iso-Align Jig
13. Rotate Gantry to 50 degrees and 310 degrees to check the 100cm ODI reading is
stable at both angles
14. Enter success or failure of above on the chart
c) Accuracy of the Optical Field Size

Limit = +/- 0.2cm1
Asymmetrical Mode (10cm x 10cm)
Note: Only one quadrant must be checked daily (i.e. either a, b, c or d).
1. Rotate the Gantry to 0
2. Set the Clinac Jaws to ASSYM such that:
a. Y1 = 0, Y2 = 10, X1 = 0, X2 = 10
b. Y1 = 0, Y2 = 10, X1 = 10, X2 = 0
c. Y1 = 10, Y2 = 0, X1 = 10, X2 = 0
d. Y1 = 10, Y2 = 0, X1 = 00, X2 = 10
3. Check correlation of the light field with the edge of the 20cm markings on the upper
surface of Iso-Align Jig.
4. On the chart record, the quadrant checked and enter a success or failure on the
chart.
Symmetric Mode (10cm x 10cm)

1. Set a 10 x 10cm symmetric field using the digital readout
2. Check correlation of the light beam with the 10cm square marked on the upper
surface of the Iso-Align Jig.

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surface of the Iso-Align Jig.
d) Correlation of the physical collimator angle with the digital readout.

Limit = +/- 1 degrees.1
1. Open the field dimension to approximately 40 x 40cm
2. Rotate the collimator to either 45 or 315 degrees
3. Check the crosshairs align with the corner field border marks on the Iso-Align Jig
e) Red Laser alignment

The limit for misalignment of the laser system is the width of the laser or 0.2cm
whichever is less. 1
Overhead Laser
1. Ensure collimator is at 0 degrees
2. Rotate the gantry off zero degrees until the overhead laser can be visualised on the
Iso-Align Jig
3. Check that the overhead laser aligns with the crosses of the Iso-Align Jig.
Lateral Lasers
1. Carefully rotate the Iso-Align faceplate to a face the 90 degree
2. Confirm the lateral lasers align with the crosshairs marked on each side of Iso-Align
Jig
3. Rotate the gantry to 270 degrees, then 90 degrees
4. Check the Linac collimator crosshairs align with the Iso-Align Baseplate crosshairs at
each gantry angle
Sagittal Lasers
1. Check that the sagittal laser aligns with the scribed mark on the foot end of the Iso-
Align Jig.
f) MV Functionality/Geometry Test
The limit for misalignment of the field size is 0.2cm.
Inside Bunker
1. Ensure the Iso-Align Jig is rotated to 90 degree vertical position
2. Rotate the Gantry to 90 degrees

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3. Ensure the Linac crosshairs correspond with the crosshairs marked on the Iso-Align
Jig
4. Maintain 100cm SSD to the surface of the Iso-Align Jig
5. Set 15cm x 15cm field size on digital readout
6. Move the MV Imaging arm into acquisition position
Outside Bunker
1. Open the patient named “T-LA_ Morning QA”
2. Mode up the planned image for “Field 1 – Gantry 90”
3. Acquire both the planned and open exposures
4. Ensure the 15cm x 15cm irradiated field size corresponds with the 15cm x 15cm
markers on the Iso-Align Jig, as in Figure 2. If the red irradiated field falls beyond the
outermost or innermost white radio opaque markers delineating the 15cm x 15cm
field size, notify RE and/or Medical Physics
Figure 2: Double Exposure MV image for Field size verification
g) Parallelism of the patient positioning/set-up laser system (green) with isocentric lateral
lasers (red laser).
whichever is less.1
2. Confirm the lateral isocentre (red) lasers correspond with the central axis markings
on the Iso-Align Jig
3. Using the Digital Couch Readout, lower the couch 20cm
4. Check that the lateral (green) lasers are at central axis of the Iso-Align Jig.
5. Check the opposing lateral (green) laser on the opposite side of the Iso-Align Jig
3.1.4.3 PART 3: On-Board Imager Couch Translation Check

Inside the Linac Bunker
1. Attach the OBI QA Cube to the couch top using the supplied attachment mechanism.
2. Ensure the OBI arms are in the OUT or RETRACTED position

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3. Align the couch so that the lasers and cross hairs run through the centre crosses on the
QA Cube
4. Move the couch so that the lasers and cross hairs align with the offset marker on the QA
cube
5. Remove the Bow Tie Filter
6. Leave the room activating the door interlock on the way out.
At the 4 D Console
1. Open the QA Patient
2. Select the Ant kV setup field
3. Click Mode up
At the OBI Workstation

1. Click 2D/2D Match
2. Rotate the gantry to the desired position by pressing MOTION ENABLE and >> on the
Clinac Console dedicated keyboard
3. Click download axes
4. Bring the OBI arms into position by pressing MOTION ENABLE and AUTO on the
dedicated on-board imager console until the green arrows disappear. If the green arrows
don’t disappear then slightly retract the arms, press download axes again and bring the
arms out again
5. Select the following exposure - 40kV, 25mA and 20ms
6. Ensure the camera icon is selected
7. Acquire the first OBI image by stepping on the footswitch. The first OBI image appears on
the screen
8. Click in the RT LAT kV image window to load the parameters for the next orthogonal set-
up field
9. Move the gantry to the planned position by pressing MOTION ENABLE and >> on the
Clinac Console dedicated keyboard
10. Acquire the second OBI image by stepping on the footswitch. The second OBI image will
appear on the screen
11. Click Analyse
12. A new workspace will appear where you must manually adjust the reference and
treatment images so that they accurately overlay each other
a) Click on the new kV AP image and apply the ‘INVERT’ filter to the image. Adjust the
windowing level so that the ball bearing can be seen clearly. Repeat with the RT LAT
image
b) Align both images
13. Check that the couch motion values required to achieve alignment between the
Reference and Acquired images are 1cm (+/- 0.2cm) for Couch Vert, Couch Long and
Couch Lat
14. Click ‘APPLY SHIFT’
15. Move the couch to the new position by pressing MOTION ENABLE and >> on the Clinac
Console dedicated keyboard
16. Retract the arms by pressing MOTION ENABLE and RETRACT on the dedicated on-board
imager console until the arms are fully retracted

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1. Enter the room and check that the lasers now fall on the isocentre of the cube (+/-
0.2cm)
2. Enter success or failure for each parameter at (h) on the Chart
Success is entered on the chart as a tick (√). Failure is entered as a cross (x)
3.1.4.4 PART 4: CBCT Imager Geometry Accuracy Check

1. Fit the Full Fan Bow Tie Filter
At the 4 D Console
1. Select the CBCT setup field
2. Click Mode up
3. Select 3D/3D Match Icon
4. Follow the On-screen instructions to acquire a CBCT image of the QA Cube using the Low
Dose Head Protocol (refer to CBCT General Instructions for use)
5. Accept and export the CBCT dataset
6. Wait for the CBCT dataset to be saved, as indicated by ‘saved 100%” message
7. Click Save Match
8. Select Cancel
9. Close Patient from 4DTC
10. Log into Offline review and ensure the acquired CBCT dataset is available to review
11. Set the acquired CBCT image to Reviewed. It is not necessary to analyse the image
match.

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LINAC DAILY GEOMETRY QUALITY ASSURANCE RECORD

(WITH OBI CAPABILITIES)
DATE
Photon Electron Photon Electron Photon Electron Photon Electron Photon Electron
Refer to fault book Refer to fault book Refer to fault book Refer to fault book Refer to fault book
Time
RE or MP Signature
PARAMETER √/x Comment √/x Comment √/x Comment √/x Comment √/x Comment
(a) Digital Couch with 100cm SSD (+/-0.2cm)
Readout = 0
(b) ODI Readout (+/-0.2cm)
ODI @ Gantry = 0
ODI @ Gantry = 50
ODI @ Gantry = 310
(c) Field Size (+/- 0.2cm)
Asymmetrical
10 x 10cm
Symmetrical
10 x 10cm
Symmetrical
15 x 15cm
(d) Collimator Angle (+/-1degree)
Coll. Rtn. +/-1 degree
(e) Isocentre Lasers [Red] (+/-0.2cm)
Lateral
Sagittal
Overhead
f) MV Imager Geometry (+/-0.2cm)
15cm x 15cm
(g) Set-up Lasers [Green] (+/- 0.2cm)
Parallel to Red
20cm below Red
h) OBI Couch Translations (+/-0.2cm)
Longitudinal
Lateral
Vertical
(i) CBCT
Functional
Exports to ARIA
RT SIGNATURE
RT NAME
DESIGNATION

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3.2 Linac 2 Geometry QA and Imaging System Checks

Daily Linear Accelerator (Linac) Geometric Quality Assurance must be performed each
morning prior to commencement of treatment delivery and following the repair of
equipment to ensure operation within accepted tolerances. It is to be undertaken by an
accredited Radiation Therapist. It applies specifically for Linac 2.
The aims of the Daily Linac Geometry Quality Assurance checks are to ensure:
 correct daily handover procedures are observed prior to treatment delivery
 Linac geometry meets acceptable limits
 the simulated treatment geometry can be accurately reproduced on a daily basis at the
Linac
Critical features of the Geometry Check are:

 Accuracy of the Optical Field Dimension
 Accuracy of the Collimator Angle
 Accuracy of the Gantry Angle
 Correlation of the Mechanical Isocentre of the Gantry with the 100cm reading on the
Optical Distance Indicator (ODI)
 Correlation of the Optical Laser System (red) with the beam isocentre
 Parallelism of the patient positioning/set-up laser system (green) with isocentric lateral
lasers (red)
 Correlation of longitudinal, lateral and vertical physical couch motion with the Digital
Couch Readout
Success is entered on the chart as a tick (√). Failure is entered as a cross (x). This procedure
assumes IEC1217 scales for all machine mechanical parameters.
3.2.1 Responsibilities
3.2.1.1 Radiation Engineering Staff (RE)
Prior to the daily release/handover of the Linear Accelerator, the RE staff will perform
morning run-up to ensure the Linac is free from faults and dose output, for all beam
energies, is within acceptable limits.
The RE staff member will complete the checkmark(s), time and sign the appropriate section
of the Linac Daily Geometry Quality Assurance Log to indicate the Linac is fit for clinical use.
Details of any failures, faults or issues will be documented in the Linac Fault book.
If any RE Staff member does not want the Linac to be used clinically, they will:
 record the relevant information in the ‘Linac 3 Fault Book'
 place a yellow ‘OUT OF SERVICE” notice on the control console key of the Linac
indicating that the machine is not to be used inform the Radiation Therapists personally
(if present)

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3.2.1.2 Radiation Therapist (RT)

When the Linac is handed over from RE, the Radiation Therapists must complete the Daily
Machine Geometry Checks to determine the accuracy of the treatment geometry system.
The following documentation contains procedural instruction and the current acceptable
limits for daily geometric quality assurance checks.
If any geometry or functionality failures are detected during this process, the RT staff must
contact the RE staff to have the issues rectified prior to clinical use. RT staff are required to
log any failures in the Linac Log/Fault Book. RT staff are only to take responsibility for the
Linac after notation is dated and recorded in the Linac Log/Fault Book, from either RE or
Medical Physics, stating the Linac is “Fit for Clinical Use”
3.2.2 Equipment & Materials

The following equipment is required to successfully perform the Daily Linac Geometry
Quality Assurance checks:
 Linac Log/Fault Book
 Iso-Align Geometry Faceplate
 Spirit Level
 Front Pointer and Mount
 Linac Daily Geometry Quality Assurance Record (hereafter referred to as the “chart”)
Figure 1: Iso-Align Geometry Faceplate

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3.2.3 Sequence of Actions

3.2.3.1 PART 1: Dose Output Check
 Check the Daily Geometry Quality Assurance Record; identify the RE staff’s entry and
signature indicating Dose Output Checks have been successfully performed.
 Success is entered on the chart as a tick (√). Failure is entered as a cross (x).
 A failure must be immediately followed up with the RE staff member on duty and
clinical treatment must not proceed until this criterion is met.
3.2.3.2 PART 2: Linac Geometry Accuracy Check

CRITERIA:
The criteria for the success or failure when testing each parameter are based on the
manufacturer’s specifications or, in the absence of manufacturer’s specifications, on the
advice of the Senior Radiation Oncology Medical Physicist (ROMP).
Success is entered on the chart as a tick (√). Failure is entered as a cross (x) with a comment
to describe the nature and extent of the variation e.g. (x) 3mm sup.
All failures are to be discussed with RE staff and entered in the Linac Fault/Log Book found
in the Linac Control Room.
PROCEDURE: 2
h) Digital Couch Vertical Readout Correspondence.

The limit for variation of the digital couch vertical readout is +/-0.2cm.
This part of the procedure does not require the Iso-Align Faceplate
1. Using the ODI set 100cm FSD to surface of the solid carbon fibre couch top.
2. Ensure digital couch vertical readout equals 0 (+/-0.2cm).
i) ODI/Mechanical Isocentre Verification

Limit = +/- 0.2cm1
1. Place the Iso-Align Baseplate onto the Yoga Mat on the Linac couch top.
2. Using the spirit level ensure the Iso-Align Baseplate is level in both planes. Adjust the
levelling feet as necessary.
3. Rotate the Iso-Align Faceplate to the horizontal plane and lock into place using the
side mount locking mechanism.
4. Align the Linac Crosshairs with the Iso-Align Faceplate Crosshairs
5. Do not move the Iso-Align Faceplate until instructed
6. Attach the mechanical front pointer mechanism to the collimator.
7. Insert the front pointer and adjust to the 100cm marking
8. Adjust the couch vertical until the tip of the mechanical front pointer touches the
surface of the Iso-Align Face Plate
9. Remove the mechanical front pointer and front pointer mechanism
10. Switch on the ODI and check that the Digital Readout equals 100cm
11. Check the horizontal lasers skim the surface of Iso-Align Faceplate

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12. Rotate Gantry to 50 degrees and 310 degrees to check the 100cm ODI reading is
stable at both angles
13. Enter success or failure of above on the chart
j) Accuracy of the Optical Field Size

Limit = +/- 0.2cm1
Asymmetrical Mode (10cm x 10cm)
Note: Only one quadrant must be checked daily (i.e. either a, b, c or d).
1. Rotate the Gantry to 0
2. Set the Clinac Jaws to ASSYM such that:
a) Y1 = 0, Y2 = 10, X1 = 0, X2 = 10
b) Y1 = 0, Y2 = 10, X1 = 10, X2 = 0
c) Y1 = 10, Y2 = 0, X1 = 10, X2 = 0
d) Y1 = 10, Y2 = 0, X1 = 00, X2 = 10
5. Check correlation of the light field with the edge of the 20cm markings on the upper
surface of Iso-Align Faceplate.
6. On the chart record, the quadrant checked and enter a success or failure on the
chart.

surface of the Iso-Align Faceplate.

surface of the Iso-Align Faceplate.
k) Correlation of the physical collimator angle with the digital readout.

Limit = +/- 1 degrees.1
1. Open the field dimension to approximately 40 x 40cm
2. Rotate the collimator to either 45 or 315 degrees
3. Check the crosshairs align with the corner field border marks on the Iso-Align
Faceplate
l) Red Laser alignment

Limit = width of the laser or 0.2cm whichever is less. 1
Overhead Laser
1. Ensure collimator is at 0 degrees
2. Rotate the gantry off zero degrees until the overhead laser can be visualised on the
Iso-Align Faceplate
3. Check that the overhead laser aligns with the crosses of the Iso-Align Faceplate.

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Lateral Lasers
1. Carefully rotate the Iso-Align faceplate to a face the 90 degree
2. Confirm the lateral lasers align with the crosshairs marked on each side of Iso-Align
Faceplate
3. Rotate the gantry to 270 degrees, then 90 degrees
4. Check the Linac collimator crosshairs align with the Iso-Align Baseplate crosshairs at
each gantry angle
Sagittal Lasers
1. Check that the sagittal laser aligns with the scribed mark on the foot end of the Iso-
Align Faceplate.
m) MV Functionality/Geometry Test
The limit for misalignment of the field size is 0.2cm.
Inside Bunker
1. Ensure the Iso-Align Faceplate is rotated to 90 degree vertical position
3. Ensure the Linac crosshairs correspond with the crosshairs marked on the Iso-Align
Faceplate
4. Maintain 100cm SSD to the surface of the Iso-Align Faceplate
5. Set 15cm x 15cm field size on digital readout
6. Move the MV Imaging arm into acquisition position
Outside Bunker
1. Open the patient named “T-LA2 Morning QA”
2. Mode up the planned image for “Field 1 – Gantry 90”
3. Acquire both the planned and open exposures
4. Ensure the 15cm x 15cm irradiated field size corresponds with the 15cm x 15cm
markers on the Iso-Align Faceplate, as in Figure 2. If the red irradiated field falls
beyond the outermost or innermost white radio opaque markers delineating the
15cm x 15cm field size, notify RE and/or Medical Physics

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Figure 2: Double Exposure MV image for Field size verification
n) Parallelism of the patient positioning/set-up laser system (green) with isocentric

lateral lasers (red laser).
whichever is less.1
2. Confirm the lateral isocentre (red) lasers correspond with the central axis markings
on the Iso-Align Faceplate
3. Using the Digital Couch Readout, lower the couch 20cm
4. Check that the lateral (green) lasers are at central axis of the Iso-Align Faceplate.
5. Check the opposing lateral (green) laser on the opposite side of the Iso-Align
Faceplate
o) Correlation of longitudinal, lateral and vertical physical couch motion with digital
readout.
Limit = +/- 0.2cm
1. With the Gantry on 0 degrees
2. Raise the couch so that the lateral isocentre (red) lasers correspond with the central
axis markings on the Iso-Align Faceplate
3. Using the Digital Couch Readout, raise or lower the couch 10cm
4. Confirm the lateral isocentre (red) laser now runs through the 20cm markings on the
upper or lower surface of Iso-Align Faceplate.
5. Move the couch back so that the lateral isocentre (red) lasers correspond with the
central axis markings on the Iso-Align Faceplate.
6. Using the Digital Couch Readout, move the couch 10cm in or out from the gantry.
outer or inner surface of Iso-Align Faceplate.
8. Move the couch back so that the lateral isocentre (red) lasers correspond with the
central axis markings on the Iso-Align Faceplate.
9. Carefully rotate the Iso-Align faceplate to a horizontal position.
10. Using the Digital Couch Readout, move the couch 10cm left or right.
lateral surface of Iso-Align Faceplate.

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Section 4 – Shutdown Procedures(WITHOUT OBI CAPABILITIES)
LINAC DAILY GEOMETRY QUALITY ASSURANCE RECORD
DATE
Photon Electron Photon Electron Photon Electron Photon Electron Photon Electron
Refer to fault book Refer to fault book Refer to fault book Refer to fault book Refer to fault book
Time
RE Signature
PARAMETER √/x Comment √/x Comment √/x Comment √/x Comment √/x Comment
(a) Digital Couch with 100cm SSD (+/-0.2cm)
Readout = 0
(b) ODI Readout (+/-0.2cm)
ODI @ Gantry = 0
ODI @ Gantry = 50
ODI @ Gantry = 310
(c) Field Size (+/- 0.2cm)
Asymmetrical
10 x 10cm
Symmetrical
10 x 10cm
Symmetrical
15 x 15cm
(d) Collimator Angle (+/-1degree)
Coll. Rtn. +/-1 degree
(e) Isocentre Lasers [Red] (+/-0.2cm)
Lateral
Sagittal
Overhead
f) MV Imager Geometry (+/-0.2cm)
15cm x 15cm
g) Set-up Lasers [Green] (+/- 0.2cm)
Parallel to Red
20cm below Red
h) Couch Translations (+/-0.2cm)
Longitudinal
Lateral
Vertical
RT SIGNATURE
FULL NAME
DESIGNATION
This section describes the correct shutdown sequence for all Linear Accelerators.
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4.1 Procedure
This procedure is to be followed when routine shutdown is performed at the end of clinical
operation each day.
NOTE LA3+4 Only: The Emergency Door Release Key is kept on the Linac key ring. It is not to
be kept in the lock itself as there is a risk of breakage.
4.1.1 Inside the Bunker

All Linacs:
1. Turn on the room lights; lasers off
2. Fully retract the MV detector, kV source and kV detector
3. Rotate the gantry to 120 degrees
4. Rotate the collimator to 90 degrees
5. Remove all items from the couch top, hereafter referred to as the couch
6. Fully retract and lower the couch
7. Fully open the neutron door
a) LA3+4 Only: Fully depress the Emergency Door Release button to disengage the
neutron door mechanics. The Emergency Door Release button, located in the LA3
maze, is clearly labelled.
LA4 Only:
8. Attach the charging power cable to the robotics couch charging outlet. Ensure the green
battery charging indicator on the side of the couch is flashing.
9. Turn on the ExacTrac Robotics using the Emergency Robotics Red button
10. Ensure the battery charger LED is illuminated green
11. Ensure all three bards of the battery LED are blinking
4.1.2 In the Control Room

All Linacs:
1. Close the treatment application
2. Select the Millennium MLC Icon
3. From the File Menu, select Open patient
4. Open Weekday or Weekend MLC File
5. Check “Park, Clinac (.)”
6. Select confirm
7. Switch off the MLC controller
8. Select Cancel to “Millennium MLC Treatment Workstations Timeout” pop up window
9. Shutdown the 4DTC Computer
10. LA1, LA3 & LA4: OBI Shutdown
i) Close the OBI application
ii) Shutdown the OBI Computer
iii) Turn off the OBI X-ray Generator on OBI console
11. Close the Linac Console back to Clinical Mode by repeatedly selecting F1
12. Remove the key from the Clinac console
13. Switch the electronics cabinet to Standby position
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14. Remove the key from the Electronics Cabinet and store both Linac keys and the
Emergency Door Release key on the LA4 key ring in the Radiation Therapy Key Cupboard
in the Planning Room
15. Shutdown all other ARIA and ACTGov computer applications and PC’s
16. Switch off the Night Switch which is located above the CCTV monitors
4.2 LA1 Daily Machine Shutdown

1. Ensure MV Imaging Arm and kV Source and kV Detector are fully retracted
2. Rotate Gantry to 120 degrees
3. Rotate Collimator to 90 degrees
4. remove all items from the treatment couch and fully lower the couch
5. Turn on the room lights; lasers off; neutron door open
6. Open the Park MLC Plans
 Double click “Millennium MLC Treatment Workstation” Icon
 Select File
 Open “Weekday” or “Weekend” MLC File
 Check “Park, Clinac (.)”
 Select Confirm
 Switch off MLC Controller
 Select Cancel to “Millennium MLC Treatment Workstation Communication Timeout”
popup window at 4DTC terminal
7. Close the 4DTC Application
8. Close the OBI Application
9. Shutdown the OBI computer
10. Shutdown the RPM computer (if used that day)
11. Turn of the X-ray Generator
12. Exit Clinac Console
 From the Clinac Mode Select F1 Exit
 Remove Key from Console
13. Switch Electronics cabinet Switch to Standby Position and remove Key
14. Shutdown all other computers including:
 ACTGov PC
 ARIA Edit Station
15. Switch off Night Switch (White switch behind monitors)
16. Return Keys to Radiation Therapy Key Cupboard

1. Ensure MV Imaging Arm
4. Remove all items from the treatment couch and fully lower the couch
5. Turn on the room lights; lasers off; neutron door open
 Select File

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 Select Confirm
 ACTGov PC

5. Turn on the room lights; lasers off; neutron door open;
6. Activate Emergency Door Release
 Select File
 Select Confirm
 From the Clinac Mode Select F! Exit
 ACTGov PC

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5. Turn on the room lights; lasers off
6. Attach the charging power cable to the ExacTrac Robotic couch charging outlet
7. Fully open the neutron door open
8. Activate Emergency Door Release
 Select File
 Select Confirm
 ACTGov PC
Section 5 – Pre-Treatment Quality Assurance Checks
This section describes the requirements for undertaking Pre-Treatment Verification Checks,
hereafter referred to as V1 and Day 2 Treatment Verification Checks using a plan PDF
uploaded in ARIA11.

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5.1. Alerts
Check marking the items within this Pre-Treatment Verification Template indicates you have
verified each item in its entirety in accordance with each criterion described below.
5.2. Pre-Treatment Verification Task (V1)

 Log in to ARIA
 Select the Relevant Linac Task Tab in the User Home
 Click the appropriate Pre-Treatment Check Task to hyperlink to the Documents Module
5.2.1 Create New Dynamic Document for the Pre-Treatment Verification

 Select “New” to create a new document
 Select and open the template named ‘Pre-Treatment Verification checks’
Figure 1-Selecting the Pre-Treatment Verification Template
 Ensure ARIA User ID is correctly populated in the Authored by and Supervised by

sections.
Figure 2-Completing Authored By and Supervised By
 Enter the Course, Site and Phase details in the Template Name section of the Dynamic
Document in the following format “ C1_Site_V1”

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Split the Windows

It will be easier to check the V1 Document against the Plan PDF with both documents
displayed side by side. To split the window;
 Open the correct Plan PDF document and click on the title bar of one of the windows
and drag it to one side of the screen. The box showing the window will appear.
Figure 3-Splitting the First Window
 Repeat this step for the second window you want to view, but by dragging it to the
opposite of the screen.
 Both windows will now be displayed side by side allowing easy comparison of
parameters and any other relevant information.
NOTE: Some of the smaller computer monitors may not split the screens evenly, leaving
some overlap of the two windows in the middle. You may choose continue like this or
manually drag the inner borders of each window to fit to your liking.
5.2.2 Documents Management Section

Plan PDF authored by Planning RT
Ensure the Radiation Therapist responsible for planning the case has been selected from the
dropdown menu in the Authored By Item for the Plan PDF.
Plan PDF supervised by Planning RT

Ensure the Radiation Therapist responsible for planning the case has been selected from the
dropdown menu in the Supervised By Item for the Plan PDF.
Plan PDF approved by Radiation Oncologist

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Ensure the Plan PDF has been approved by the RO. This electronic password protected
approval serves as the Radiation Oncologists signature. Treatment must not proceed until
this item has been check marked.
5.2.3 Treatment Plan Review

Plan reviewed by Treatment RT
Briefly review the treatment plan to ensure the technique is understood by the Radiation
Therapist responsible for commencing the first treatment fraction.
Clarify any anomalies with the planner or a Senior RT and add these anomalies to the NOTES
dialogue box at the bottom of the V1 Dynamic Document.
Prescription matches Treatment Sheet

Ensure the prescription on the Plan PDF matches the Treatment Sheet.
5.2.4 Treatment Sheet Review

Treatment Sheet Prescription signed by Radiation Oncologist
Ensure the prescription has been signed by the Radiation Oncologist.
Fractionation indicated
Ensure the Radiation Oncologist has indicated the number of treatments per fortnight. If 10
per fortnight has this been noted on the treatment sheet add a yellow sticker to the front of
the treatment sheet and the blue file.
Bi-daily in Short Weeks

Ensure the Radiation Oncologist has indicated any need for bi-daily treatment on short
weeks (public holidays). Follow-up as necessary. Mark this item not applicable as
appropriate.
Treatment Sheet signed by Planning RT

Ensure the Treatment Sheet been signed by the Planning RT
Treatment Sheet countersigned for NPDP RT

Ensure the Treatment Sheet been signed by a fully accredited RT.
Mark this item not applicable as appropriate.
Prelim/Final Check Signature

Ensure there is a Preliminary or Final Check Signature present. If there is a preliminary
check, ensure it is noted on the file to return to Planning.
Patient Position matches CT Record

Ensure the patient position and set-up/immobilisation devices recorded on the CT Record
match the Treatment Sheet.
CT Reference Point location correctly transcribed from CT Record

Ensure the CT Reference Point location is correctly transcribed from the CT Record onto the
Treatment Sheet.

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Iso Location corresponds with plan

Ensure the location of the isocentre on the Treatment Sheet matches that of the Plan PDF.
Iso setup FSD/instructions correspond with plan

Ensure the setup FSD and set-up instructions are clearly documented in the treatment sheet
and match the plan.
Bladder Filling/Special Instructions

Ensure any special instructions requested by the doctor as clearly documented. These may
include Empty/Full Bladder for treatment, TLD requests, dietary requests for the patient etc.
Bolus correctly indicated/described

Ensure the bolus (if any) has been indicated on the Treatment Sheet and is clearly described.
Landmark diagram accurate and complete (if applicable)

Ensure the measurements on the Landmark diagram match those of the Plan and CT Record.
Ensure all the measurements required for treatment are present. Mark this item not
applicable as appropriate.
Tattoos indicated
Ensure all tattoos, both new and previous, are clearly indicated. Ensure their location in
relation to the isocentre is clear.
Accessory Equipment at Linac

Ensure all the necessary equipment to treat the patient at the Linac. Ensure it is correctly
labelled and orientated.
5.2.5 Data Integrity Checks

Volume/Plan Name corresponds with site
The volume name in the geometric parameters section of the treatment sheet must match
the Plan name in ARIA. This generally the site being treated (e.g. Prostate, Lt SCF, Rt Breast,
and Brain).
Field ID (Number Only)

The row containing ‘Field ID’ on the Treatment Sheet and in ARIA equals the beam number
only. It does not include field name or volume name in ARIA.
Machine ID
Ensure the Machine ID for each field in ARIA corresponds with the machine in which that
patient will be predominantly treated on.
Field Name (Name Only)

Do the field Names match on each the Treatment Sheet, ARIA and the Plan PDF? Ensure the
field Name does not include the Field ID.

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Energy/Mode
Using the Plan PDF as reference, ensure the Energy/Mode in ARIA and the Treatment Sheet
are correct.
Dose Rate
Ensure the dose rate correctly selected/populated in ARIA for each field.
MU
Using the Plan PDF as reference, ensure the MUs for each field in ARIA and on the treatment
sheet are correct.
Time
Ensure the treatment time documented on the treatment sheet is correctly calculated on
the treatment sheet and matches in ARIA. The correct computation of time for:
 IMRT is MU’s divided by 80
 Forward Planned is MU’s divided by 300
 all static beams is MU’s divided by 450
Tolerance Table
Ensure each beam has the correct Tolerance Table attached in both the Treatment Sheet
and in ARIA. Set-up fields should have the same Tolerance table as the treatment fields.
Refer to Section 26 of the External Beam Operations Manual for the tolerance table
parameters.
Planned SSD
Using the Plan PDF as reference, ensure the FSDs for each field match the Treatment Sheet
and ARIA.
Gantry Rotation
Using the Plan PDF as reference, ensure the Gantry Angle for each beam matches in the
Treatment Sheet and in ARIA.
Collimator Rotation
Using the Plan PDF as reference, ensure the Collimator angle for each beam matches the
Treatment Sheet and ARIA.
Collimator Rotation of kVs match first treatment field

Ensure the collimator angles of the kVs set-up fields match the collimator angle of the first
field that will be treated.
Jaw Settings
Using the Plan PDF as reference, ensure the X1, X2, Y1 and Y2 jaws for each beam match the
MLC
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Are the MLCs (If any) are indicated on the Treatment Sheet and in ARIA for the each beam.
Wedge Angle/Code/Orientation
Using the Plan PDF as reference, ensure the Wedge Angle, Code and Orientation match the
Electron Applicator/Insert
Using the Plan PDF as reference, ensure the Electron Applicator matches the Treatment
Sheet and ARIA. Ensure the Electron Insert is entered on the Treatment Sheet in Red Ink.
Bolus
Ensure bolus (if any) is indicated on the Treatment Sheet field parameters section in green
ink. Ensure a Bolus Interlock has been activated in ARIA for each beam containing Bolus.
Couch Values/ MV Imager Values

Ensure appropriate couch vertical, longitudinal and lateral values have been populated in
ARIA and the imager vertical value has been set at 50.
Floor Rotation
Using the Plan PDF as reference, ensure the Floor/Couch Rotation for each beam matches
the Treatment Sheet and ARIA.
Patient setup documented in ‘Setup Note’

Ensure the patient ‘Setup Note’ in ARIA match that of the Treatment Sheet. Ensure the note
is as brief as possible whilst ensuring all essential information/equipment to treat the
patient is visible.
Field Sequencing is logical (Including imaging)

Ensure the beams are ordered according to department policy. This will generally
correspond with the order in which the treatment sheet has been written up. Ensure the
imaging fields been created with the most appropriate beam angles.
Plan Valid for Treatment (Treatment Approved)

Ensure the plan suitable to use for treatment and it has been Treatment Approved.
5.2.6 Reference Point Section

Field Dose
Ensure the daily filed dose contribution for each beam in ARIA matches the Treatment
Sheet. Be aware of any effect that adjustments may have on MU.
Daily Dose
Ensure the daily dose to each Reference Point corresponds with the daily dose recorded on
the prescription page.
Total Dose
Ensure the Total Dose for each Reference Point equals the total prescribed dose(s).

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Breakpoint
Ensure there are Breakpoints for all Reference Points at the correct doses/fractions in the
Treatment Sheet and in ARIA.
5.2.7 Plan Scheduling

EPI/kV/CBCT images scheduled
Ensure all the correct images been scheduled for the correct fractions. This includes any
type of MV, kV or CBCT imaging.
Appropriate Anatomy outlined

Is there any drawn anatomy outlines on the setup DRR’s and is it suitable for the imaging
required.
Imager Offset
Ensure the imager (kV or MV) offset is calculated to capture the appropriate anatomy
needed for matching. Enter imager offset using the Imager Vrt, Lng and Lat Values in Plan
Parameters (or Treatment Preparation). The imager offset program located on the G drive
can be used for MV offset for asymmetrical fields.
Weekly Chart Check Tasks Scheduled

Ensure that the weekly chart check tasks have been scheduled appropriately in the patients
care path.
Planned number of fractions match booking

Ensure the scheduled number of bookings in CAS and ARIA matches the prescription.
5.2.8 Other
Plan Treatment Approved
Ensure that every plan that has been validated and treatment approved in the plan
parameters tab.
Appropriate BTE’s/minutes booked

Confirm adequate appointment time has been allocated to the patient/technique. Things to
take into consideration include the patient’s mobility and complexity of setup. Discuss
required modifications with the Senior RT.
“Phase 2 Start” indicated as a booking note

Is there an appointment note attached to the first day of a new phase in CAS/ARIA to help
give notice to staff if a check is to be done.
Activity Capture Codes pre-filled in patient care path

Ensure the Activity Capture Codes have been pre-filled in the patient’s Care Path.
To pre-fill, Navigate to the Care Path tab of Patient Manager, click the ‘Care Path’ tab next
to the ‘Visual Care Path’ tab. Populate the appropriate billing codes and imaging

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requirements for the course of treatment. Refer to section 11 for RT billing codes of the
External Beam Operations Manual.
Primary RO assigned in Patient Manager

The primary RO must be assigned in the associated provider tab of patient manager to
ensure all images are assigned to the RO’s image review work list.
Inpatient/Outpatient status correct in Patient Manager

Ensure the ‘Inpatient’ check box been ticked if the patient is an inpatient.
‘Course’ Assigned in Patient Manager (NB. NOT ‘New Course’)

Is the course status set to ‘Course’ and not ‘New Course’?
Consent Form signed/witnessed

Has the Consent Form been signed or witnessed by the patient/carer?
Gown Organised
Has a gown (if necessary) been organised? Consider the patient’s mobility/ability to getting
changed and the site being treated.
Patient Alert for MLC Check created (All Phases)

Has a Patient Alert been created to remind the treatment staff to check any MLC’s. A second
alert should be entered for the date where a new phase is to be commenced.
V/V1 Signature
Are the initials of staff member who entered the plan data into ARIA on the Treatment
Sheet in the ‘By’ column of the ARIA Entries section? Have you placed your initials next to
this in the ‘V1’ column?
Notes checked for presence of Pacemaker or Defibrillator

Have you checked the patient’s notes as to whether or not they have a pacemaker or
defibrillator? If the patient has a Pacemaker or Defibrillator:
 ensure it been noted on the Treatment Sheet setup page and in the ARIA ‘Setup Note’
 determine if a magnet required to place on top of the device
 Ensure the patient has received their times for their Cardiology Appointments after
treatment and that they are indicated on the treatment sheet
 Create a Pacemaker Alert in ARIA
NOTE: If there are any additional comments that need to be documented, they may be
done so in the grey text box next to ‘Notes’ found underneath the V1 section of the
document.
5.2.9 Creating a New Patient Alert

Patient Alerts are used if critical information is to be communicated to the treatment team
 Navigate to summary page in patient manager

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 Patient Alerts are displayed in the bottom, right of the page.

 To create a new entry right click and select new.
 Enter in the required information in the dialogue box that appears. See figure 4
 Ensure the display date is correct for the patient’s next treatment appointment specific
to that alert
 Select ok.
Figure 4: Patient Alerts Dialog
5.2.10 Signing off the Pre-Treatment Verification Check

Once the V1 section of the document is completed, click the ‘Sign Off’ button and enter your
username and password.
Figure 5: Sign Off Button
This will stamp the document with your name, the date, and the time whilst allowing the
document to stay open for the staff member performing the Day 2 Verification Check.
5.3 Completing the Post Initial Treatment QA (V2)

 Log in to ARIA
 Select the Relevant Linac Task Tab in the User Home
 Click the appropriate Post Initial Treatment QA (V2)Task to hyperlink to the Documents
Module
NOTE: By ticking any item within this Dynamic Document indicates you have verified each
item in its entirety as described for each one below. V1 ‘Signed Off’

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Ensure the staff member who completed the V1 has performed a ‘Sign Off’ in ARIA. If so,
their name and the date/time of when this was done will be stamped at the bottom of the
V1 section of the document.
Amount of time allocated for the patient still appropriate

Following assessment of the patient and their treatment on day 1, ensure the time allocated
to the patient is still appropriate for each of the remaining fractions. Was the patient mobile
enough or was the treatment too complicated for the specified time? Initiate discussion
with the Senior RT.
ARIA Dose Accumulation history correct

Ensure the recorded dose in ARIA matches what was prescribed for each fraction.
MU for each Field correct

Ensure the recorded MUs for each treated field match the planned MUs.
MLC’s Checked
Ensure a qualified RT’s signatures or initials are present on each of the MLC printouts to
indicate that they have been checked. Ask the staff who treated Day 1 if unsure. MLC
templates should be disposed of in the confidential waste bins after the V2 check.
Set-up Equipment change reflected in ARIA

If there were any changes to the treatment Set-up Day 1, ensure they have they been
changed in the ARIA Set-up note.
Tolerance Table updated on Treatment Sheet

Ensure the Tolerance Table for any of the fields is updated/changed as appropriate.
Auto EPID positions entered into ARIA

If an EPI was taken on day 1, were the EPID positions recorded and entered into ARIA
allowing for greater ease of use for the next fraction that images are taken?
Photos taken and attached

If any photos taken Day they need to be attached to the treatment sheet or in ARIA.
Gantry/Coll/Floor Angles updated on Treatment Sheet

If Day 1 treatment was used to determine the best Gantry/Coll/Floor Angles for treatment,
ensure they have been updated (using pen) on the treatment sheet.
Gantry/Coll/Floor Angles updated in ARIA

If Day 1 treatment was used to determine the best Gantry/Coll/Floor Angles for treatment,
ensure they been updated in ARIA using the ‘Plan Revision’ feature.
Couch Vert. Readout details on Treatment Sheet match ARIA

Ensure the inked in Couch Vertical value match that of the Couch Vertical value in ARIA.

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Documented V1/Day 1 comments followed up

Ensure any comments/instructions documented for the staff to follow up after day 1 have
been actioned.
File to planning for Final Check and/or amendments?

Check if the plan needs to be returned to planning for a final check and if the
plan/treatment sheet needs any changes or fixes made to it following the first treatment.
Activity Capture Codes correct

Ensure the correct Activity Codes have been attached to the Day 1 Treatment and that they
are still correct for the remaining treatments.
Patient Contact Details correct

Ensure the patient’s contact details have been checked, that they are correct and if the
patient needs to be asked for any other details.
V1/V2 signatures complete

Check if there are any initials on the treatment sheet to indicate that the V1 has been
completed and ensure you have placed your initials in the V2 column next to it.
If there are any additional comments that need to be documented, they may be done so in
the grey text box next to ‘Notes’ found underneath the V2 section of the document.
5.3.1 Approving the Treatment Verification Check Document

 Once the V2 section of the document is completed and it has been checked that the V1
section has been ‘Signed Off’, click the ‘Approve’ button.
Figure 6: Approve Button
 Enter your details and click ok.

 This will stamp the document with your name, the date, and the time. It will also lock
the document not allowing any modifications of the document to be made. If
something was forgotten or entered incorrectly, the document will have to be marked
as an error and started again.

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Section 6 – Daily Machine Parameter Checks
To verify that the treatment parameters transcribed to the treatment sheet are consistent
with the actual machine settings for a patients treatment, to ensure safe and accurate
delivery of radiation therapy treatment to patients.
6.1 First Treatment Fraction

The first treatment fraction of all new courses of treatment, new phases of treatment or
changes in existing courses of treatment must include a check of all the parameters listed
below prior to leaving the treatment bunker. The Radiation Therapist who will switch on the
Linear Accelerator will verbally recall detail from the treatment sheet and the second
Radiation Therapist will verify settings from the actual machine:
 Treatment Site
 Positioning Details
 Reference Point location
 Isocentre Location
 Set-up FSD
 ATT (if applicable)
 Electron Applicator and Insert (if applicable)
 Bolus + Thickness (if applicable)
 Other personalised accessory equipment
For patients who have daily imaging or pre treatment imaging on the first fraction the
following parameters should be checked at the treatment console after imaging has been
performed, but prior to treatment field delivery. For patients who do not have pre
treatment imaging on the first fraction the following parameters should be read out in the
treatment bunker prior to leaving.
 Collimator Angle
 Gantry Angle
 Each Jaw Setting
 Couch Rotation (if applicable)
 Wedge Angle
 Wedge Orientation
 MLC placement
6.2 All subsequent treatment fractions

At subsequent treatment fractions the jaw settings, gantry rotation, collimator rotation,
couch rotation, MLC placement and wedge orientation are not required to be verbalised.
The Radiation Therapist who will switch on the Linear Accelerator will verbally recall the
following detail from the treatment sheet and the second Radiation Therapist will verify
settings from the actual machine:
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 Treatment Site
 Isocentre Location
 Set-up FSD
 ATT (if applicable)
 Wedge Angle (if applicable)
 Electron Applicator and Insert (if applicable)
 Bolus + Thickness (if applicable)
 Other personalised accessory equipment
NOTE: 1) The treatment sheet is regarded as the primary source of treatment information
2) The treatment sheet must be taken into the bunker for all patient set-ups
Section 7 – Weekly Chart Checks
This section describes the requirements for undertaking a Weekly Chart Check using the
Chart QA module of ARIA11.
7.1 Alerts
 Each RT must ensure they are logged into ARIA using their own login account.
 Placing a Checkmark against each of the criteria indicates that the item has been
completed and/or follow-up action initiated.
7.2 Initiating a Weekly Chart Check

 Log in to ARIA
 Select the appropriate Linac Tasks Workspace/Tab from the user home
 Select the Weekly Chart Check task to auto assign the logged in user as the task owner
and hyperlink to Chart QA
 To load an encounter Click on the Encounters tab
 Select New
 From the Type drop down menu, select RT- Weekly Chart Check

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Figure 1: Chart Check Template
7.3 Review Dose

 From the Dose Summary Section;
o Select Review Dose
 For the Course being treated, review Dose/Fx, #Fx, Total Dose
 Note the number of remaining fractions for use in the next section.
 Tick the box to indicate this item has been completed
Figure 2: Radiation Plan Review
7.4 Remaining Appointments

 Select the Remaining Appointments Menu Item.
 From the Appointments Tab, review all scheduled appointments ensuring:
o the correct numbers of remaining appointments have been scheduled.
o the correct numbers of fractions per fortnight have been scheduled.

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o adequate appointment time has been allocated to the patient

o the appointment type is correct.
 To open or add appointments, right mouse click the Appointments tab and select the
appropriate option.
Figure 3: Remaining Appointments Review
7.5 Review Tasks

 Select the Review Tasks Menu Item.
 From the Task Tab ensure;
o all overdue/outstanding treatment tasks have been followed up/actioned prior to
setting them to complete.
o all upcoming tasks have been correctly scheduled
 To open or add tasks, right mouse click the Tasks tab and select the appropriate option.
7.6 Review Patient Notes/Journal Entries

 Review all Journal entries and ensure any follow-up action is initiated:
RO Notes
Review all the RO Journal entries and ensure all items have been appropriately
actioned.
Nurses Notes
Read through all the Nursing Journal entries and ensure all documented items have
been appropriately actioned.

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RT Notes
Read through all the RT Journal entries and ensure all documented items have been
appropriately actioned.
Patient Alerts
Review all patient alerts and ensure they have been appropriately actioned.
 An occasion of service needs to be added in CAS for all Radiation Oncologist, and
registrar reviews. The Radiation Therapist will write a note in the treatment sheet
indicating the date the patient was seen, who saw the patient and sign the "Action By"
column so that other Radiation Therapist's do not have to follow them up again. i.e.
12/06/2015 Seen by Dr XXX....... RTs sig.
 Once Journal entries have been reviewed, the menu item must be ticked off in the RT-
Weekly Chart Check Encounter. Ticking items off indicates that you have read all the
relevant entries and initiated any required follow-up action.
NOTE: If the correct type (i.e. Radiation Oncologist) is not selected when the journal note is
created then the note will not be correctly displayed in the Encounters tab, please ensure
you navigate to the Journal tab to ensure that all journal notes are reviewed.
7.7 Delivered Treatment Parameters.

This section pertains to the review of all previous fractions technical, set-up and field
geometry data.
 Navigate to the Treatment History tab.
 Ensure Show All Treatments, Hide Completed Courses, Hide Completed Plans, Hide
Retired Plans is selected.
Treatment Parameters Review

 Switch on the Data Filter
o Right Mouse Click the Blue Column Header
o Select Show Data Filter
 Use the Data Filter to select one field only by filtering by the field name

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Figure 4: Filtering by Field Name
 Review each column to ensure that the planned data (blue) matches the actual data for
the following fields:
o MU
o Energy
o Tolerance Table
o Gantry Rotation
o Collimator Rotation
o Field Size
 Repeat the process of checking field parameters for each field using the Data Filter.
Evaluate Overrides (if applicable)

 All yellow fields, indicating overrides, must be investigated and be able to justified.
o Follow-up any ambiguous overrides with the responsible RT; hover over the
highlighted field to display the RT’s initials.
o Update Plan Parameters to reflect consistently overridden couch values if they are
in the same direction and of similar magnitude. Careful assessment of these values
is required prior to actioning a change.
o Discuss any anomalies with the Senior RT or Head of Treatment prior to delivery of
the subsequent fractions.
 Navigate to the Encounters Tab
Analyse, Evaluate and Action FSD’s

 Navigate to the Treatment History Tab
 Ensure FSD's have been recorded on a weekly basis.
 Evaluate FSD’s to ascertain that they are within acceptable tolerance.

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 Arrange for repeat FSD checks to be performed if anomalies are identified. A patient
alert may be used to request repeat FSD’s.
 Return file to planning for re-calculation/replanning if 3 days of FSD changes outside
department tolerance.
 Return to the Encounters tab
7.8 Imaging Review.

Review Image Status
 Navigate to the Summary Tab
 Click on the hyperlink next to Last kV/MV Image:
o Offline Review will load a work list containing all the Patients images.
o Ensure all kV, CBCT and MV images have been set to Reviewed or Approved.
o Follow up any “NEW” images. Ensure they are analysed and set to Reviewed.
Figure 5: Offline Review Evaluation
Isocentre Trends (for OBI)

 Select the most recently acquired image
 From the Tools Menu, select Statistics/Trends
 Select the Table tab
 From the Chart Type dropdown menu select Online OBI Match Results
 To include match results from plan revisions, checkmark the Include matches from
former plans option. Ensure former courses and irrelevant plans are not included within
the tabulated data.

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Figure 6: Analysing Isocentre Shifts
 Analyse the last 3 images to identify the need for correction of any systematic shifts in
the longitudinal, lateral and vertical directions.
 Ensure the systematic corrections to the isocentre have been correctly transcribed to
the treatment record.
 Select Close.
 Select Back
Figure 7: Back Button

 Navigate to the Encounters Tab
 Tick the box for the current and previous items to indicate its completion
7.9 Other
7.9.1 Document Review
 Select Document Review from the Encounter Menu
 Review the current Course documents
 Ensure that Treatment related documents have been approved.
o Initiate any follow-up action
 If this is the first Weekly Chart Check, review the V1/V2 documents and ensure that any
comments made have been actioned
7.9.2 Activity Capture Review

 Quicklink to Activity Capture
 Open a new Patient Review for the desired patient
o Select View
o Select Add View
o Select Patient Review
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 Search for the patient using surname, first name and ID1
 Ensure the following columns are displayed:
o Patient o Hospital Procedure Code
o Activity o Staff/Resources
o In Patient Status o Diagnosis
o Course ID o Reviewed
o Date of Service o Reviewed By
o Procedure Code o Primary
o Oncologist
 Check the:
o Inpatient status is correct
o Correct Medicare Codes have been billed.
o Play close attention to the commencement of new phases etc, where codes may
have been incorrectly auto filled.
o Ensure the Patient Status is set to New Course, or Retreatment Course, for the Initial
Fraction
o Ensure the “N”(New Course) or “S”(Subsequent/Retreatment Course) suffix is
attached to the site code for the first fraction.
o Correct number of fields for each treatment have been billed
o Treatment Linac is specified
o Imaging code is correct and attached to the correct fraction
DEFINITIONS: For definitions of Inpatient status, Patient Status, Procedure Codes, Imaging
Codes please refer to Section 11 of the External Beam Operations Manual
NOTE: When changing or updating a billing code ensure the date of Service is adjusted as the
software defaults the date to the current date.
 Ensure the correct Diagnosis is attached to course

 When data has been validated or updated, highlight the relevant rows and select the
review button
 Quick link to Chart QA
7.10 Completion of Encounter

7.10.1 QA’d
 Click on the Treatment History tab.
 Click the QA’d button in the top right hand corner. The summary tab will indicate that
the patient has had a Chart Check completed.
7.10.2 Journal Note

If the Chart Check has detected any anomalies throughout the course of treatment, then a
Journal Note is to be created to document the anomaly and any follow-up action that was
undertaken.

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 Click on the Encounters tab.

 Next to the New Journal Note item, click the New Entry Icon
 The Journal dialog will appear.
 In the Details section, write in the required information
 Ensure that the Type is set to Radiation Therapist
 Click Approve. This should tick the item off in the Encounter Item list.
Figure 8: Journal Dialog
NOTE: Whilst the paper based treatment sheet is in use, all electronic journal entries must
be duplicated in the treatment sheet
7.10.3 New Patient Alerts

Patient Alerts are used if critical information is to be communicated to the treatment team
 Next to the New Patient Alert item within the encounter, click the New Entry Icon
 The Patient Alerts dialog will appear
 In the Patient Alerts section, enter in the required information.
 Ensure the display date is correct for the patient’s next treatment appointment
 Click OK.

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Figure 9: Patient Alerts Dialog
7.10.4 Finalisation of the RT- Weekly Chart Check Encounter

 To finalise the encounter checkmarks must be placed against all of the Items
 Once all steps of the RT- Weekly Chart Check Encounter have been completed (indicated
by a tick in either the Completed or N/A columns) a tick should appear next to the
current Weekly Chart Check in the Encounters list to the left.
 Select Save.
Section 8 – Course Completions, EBRT
This section outlines the steps involved in performing a Course Completion Check at the
conclusion of a patient’s course of External Beam Radiation Therapy
8.1 Initiating a Course completion check

 Click on the patient’s Final Check task from the User Home
 Within Chart QA, under the Encounters tab, click New
 Under the Type drop down menu, select RT-Course Completion.
 Placing a Checkmark against each of the following criteria indicates that the item has
been completed and/or follow-up action initiated.
8.1.1 Treatment Sheet Check

Review Dose
 Select Review Dose Encounter Item
o For the Course being treated, review Dose/Fx, #Fx, Total Dose
o Ensure there are no remaining fractions
o Ensure the paper based treatment sheet reflects the dose recorded in ARIA

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Review Progress Notes

 Review all journal entries in ARIA and hand written progress notes on the treatment
sheet, ensuring all items requiring attention have been actioned
Signature Check
 Ensure all required signatures are recorded on the treatment sheet
 Ensure any signatures missing are followed up
MU Record (Treatment Sheet)

 Ensure all required MU are recorded on the treatment sheet
 Ensure any missing MU or anomalies are followed up
8.1.2 Appointment/ Task Review

Appointment Review
 Select the Appointments Review Menu Item.
 From the Appointments Tab, review all delivered appointments ensuring:
o the correct numbers of appointments have been delivered.
o Excess/unrequired appointments are deleted.
 In CAS ensure an occasion of service has been completed for each RO/registrar Review
Task Review
 Select the Tasks Menu Item and ensure:
o Review all tasks to ensure they have been set to complete.
o Follow up any anomalies and delete any excess or unrequired tasks
8.1.3 Image Review

 From the Summary tab
 Select the hyperlink next to Last kV/MV Image
 Offline Review will open a Work list displaying verification images status
 Ensure all images have been Reviewed/Approved
o Review any Unreviewed images
o If all images are approved by an RO the Review Outstanding Images task can be
deleted.
o If there are unapproved images, ensure the correct RO is assigned to the Review
Outstanding Images task.
8.1.4 RT EMR Data

Treatment Parameters Check
 From the Treatment History tab, tick Show All Treatments, Hide Completed Courses,
Hide Completed Plans and Hide Retired Plans
 Review all treatment parameters for all fractions and ensure the treated field data
matches the planned field. Follow up any anomalies.
 Ensure all fields have been set to QA’d by selecting the button in the top right hand
corner
 Click on the Chart QA Note button
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 Write ‘Final Check Completed’
Patient Alerts
 Select Patient Alerts from the Encounter
 Ensure all Patient Alerts have been signed off
 Follow-up an outstanding patient alerts
Dynamic Document Review

 Select the Documents tab and ensure all treatment related documents, such as Pre-
Treatment Verification Check (V1) are present and have been set to Approved.
 Ensure any documents that still requiring approval are followed up with the staff
responsible
8.1.5 Other Items

Activity Capture Codes
 Review all activity capture codes as outlined in the weekly chart check section 7.9.2 of
the External Beam Operations Manual
 Ensure once all relevant data has been validated or updated, highlight the relevant rows
and select the review button
Course Status Set to Completed

 If all images have been set to approve this task can be completed, if there are
unapproved images N/A should be selected and the course left as active.
 If this task is unable to be completed, staff must ensure the Review Outstanding Images
and Update Course Status tasks are present and appropriately assigned.
 Navigate to Plan Parameters from the Quicklinks Menu
 Change the status of the course to COMPLETED
 If there are items (other than reviewing outstanding images) yet to be completed for
any reason, the encounter and its associated task should be left in progress until it is
available to do so
Blue File given to Nurses

 Ensure the Blue File is initialled and forwarded to the Nurses once the final check is
complete
Templates
 Ensure any treatment templates have been scanned into ARIA prior to disposal
 Ensure the template, once scanned in, is disposed of in the confidential waste bin
Disposal of Accessories
 Ensure all electron cut-outs are clearly marked with an “F” or “Finished” and returned to
the Radiation Engineering Mould Room
 Ensure all masks and accuforms are de-identified and disposed of in the designated bin.
The bin will be stored in the treatment storage area. Arrangements will be made for the
bin to be cleared as required.
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 Ensure any custom bolus or other treatment accessories are de-identified and disposed
of correctly
8.2 Finalisation of encounter

 Navigate to Patient Encounters
 Checkmarks must be placed against all of the encounter items for the encounter to be
complete
Section 9 – Appointment Changes
This section describes the day to day use of the Appointment Scheduling Workspace within
Radiation Oncology Treatment section.
For a detailed overview of application functionality and icons refer to the Radiation Oncology
Appointment Scheduling Reference Manual
9.1 Alerts
The Read Only Account for each Linac is to be used for viewing/tracking purposes. Making,
changing appointments adding notes and completing tasks in this account is disabled. Switch
Users to log into personalised accounts with adequate rights to perform required editing
functions.
Leaving applications logged in under an individual’s account for all staff to utilise full
functionality is not permitted as it breaches ACT Health IT Security Policy. Under no
circumstances are accounts to be left logged in for others to use.
9.2 ARIA Read Only Workstation Set-up

 The Appointment Scheduling application is to be opened on the dedicated ARIA terminal
located on the clinical side of the workbench using the generic user, read only account
 The standard view for the Appointment Scheduling Workspace (Figure 1) is:
o All Linacs, SXRT and Meeting Schedule displayed
o 5 minute appointment increments
o Task Pad enabled
o Single Day View only
o Ticker enabled

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Figure 1: Standard Read Only Account Views
9.3 User Home – Linac Views

 The ARIA terminals located on the ‘non-clinical’ side of the workbench are to be logged
in using individual ARIA accounts
 Full functionality will allow users to access all relevant applications including Time
Planner and User Home
 The standard view for User Home- Linac Views (Figure 2) is:
o Tasks Only
o Available Tasks
o Two Weeks Ago to Two Weeks ahead
o Relevant Linac
o Favourites displayed
Figure 2: Standard User Home- Linac

Views

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9.4 Linac Schedule

 Linac appointments will be managed using the ARIA 11 Appointment Scheduling
workspace (formerly known as Time Planner)
 The Senior RT or their delegate is responsible for using the Appointment Scheduling
Workspace to assess and manage:
o the patient workload
o unintentional double bookings or treatment overlaps
o inpatient scheduling
o new patients allocations
o incorrect appointment durations
o appointment notes
 All available appointment slots will be utilised. There is no provision for ‘catch-up time’
 Appointments are NOT to be double booked
 Head of Treatment will optimise appointment availability on a weekly basis by reviewing
all Linac schedules. Patient appointment time changes of more than 5 minutes will be
communicated with the relevant Linac staff
 The Linac schedule is not to be printed. All patient appointments, details and
appointment related notes will be available in the Appointment Scheduling application
 10 fractions per fortnight appointments are indicated in yellow
 Nine fractions per fortnight appointments are indicated in white
 New cases or phases are indicated in green
 Final Treatments are indicated in red
 Notes not normally described in the medical record may be added as an Appointment
Note. They need to be kept to a minimum and initialled by the RT entering the note.
Some examples may include “Requires O2-BF” or “Do not move-DP” or “IP on Ward
14B-RT”
 When treating a patient from another Linac, the appropriate appointment must be
transferred across to the correct Linac in ARIA before mode up is initiated at the 4DTC. It
is acknowledged that this may result in a double booking. This must occur in order to
correctly communicate the actual treatment Linac to the Administration Billing Staff
 All machine downtime will be recorded in the relevant Linac Schedule by adding an
appointment with Activity Category = Maintenance Category and Activity = Unplanned
Linac Repair (Downtime).
 The start time for this appointment is to match the reported fault time in the Linac fault
book, the end time for this appointment is to match the time the Linac is released back
for clinical use
9.5 Linac Tasks

 A daily task work list will be displayed in the Linac User Home Tab
 All Linac tasks, such as Pre-Treatment Verification Checks (V1), Weekly Chart Check and
Finish Checks will be managed in the User Home Workspace. Using this workspace will
ensure the:
o user is hyperlinked to the most appropriate workspace
o correct user is assigned to the task

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 Tasks are not allocated to an individual; rather the entire team will work together to
complete all of the Available Tasks
 To evenly spread the administrative duties throughout the working week, tasks are to
be completed as they become available. Any overdue task will be escalated to the RT
Management Team
 A Weekly Chart Check element has been created to ensuring the sequencing and
frequency of tasks is appropriate. If a task needs to be added into the Carepath it is
essential to review the Visual Carepath to ensure the order of activities is correctly
sequenced and the link is placed in the correct place
9.6 Documentation
 Any note or documentation that would be normally recorded in a patient’s medical file
is to be recorded as a Journal Note as well as on the paper based treatment sheet
(whilst in use)
 Any urgent notes or situations affecting dosimetry are to be entered as a Patient Alert
 Appointment notes should be used as described above
 RO notes will be documented on the treatment sheet as is current practice, unless
formally advised otherwise by memorandum
 If the Radiation Oncologist or their delegate advises that the patient is not for treatment
o the patient’s appointment status must be set to cancelled
o an appropriate note attached to the appointment (e.g. As per Dr.X, patient not for
treatment- see paper based treatment sheet for note”)
o an additional appointment is to be scheduled
o review the Carepath and ensure the sequencing of appointments and tasks is
correct.
 If the Radiation Oncologist or their delegate advises that the patient is for no further
treatment
o the patient’s appointment status on the day of notification must be set to cancelled
o an appropriate note attached to the appointment (e.g. As per Dr.X, patient not for
further treatment- see paper based treatment sheet for note”)
o all remaining appointments should be deleted
9.7 Patient Appointments

 All patient treatment appointments will be printed from ARIA;
 From the Appointment Scheduling application
o select Reports
o select Clinic Reports
o select CACHS Rad Onc Patient Appointments
o click Patient List of Appointments
Figure 4: Selecting a Report

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 In the window that appears enter the patient’s MRN. If the MRN is not known, search
for the patient using the Patient Explorer tool
o Click the button to the right to bring up the Patient Explorer Window
Figure 5: Report Patient Selection
o Adjust the date range, ensuring it is adequate enough to cover the full length of the
patient’s course
Figure 6: Adjusting the Report Date Range
o Click Run Report

o A list of all the patient’s appointments for the date range chosen will appear
o To print, click the print icon at the top of the window
Figure 7: Print Icon
9.8 Patient Reviews

 Patients will continue to see the Radiation Oncologist and/or Nurses as per the
Radiation Oncology Treatment Review Schedule
 Treatment Review appointments will be scheduled in CAS by the Treatment RT’s on an
adhoc basis immediately after the treatment review (until formally advised otherwise
through memorandum)

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9.9 Days End

 Prior to the end of each day, treatment RT’s are to review upcoming (Pending)
treatment tasks from User Home to ensure anything expected for the next morning is
actioned/altered
 At the end of each working day treatment RT’s are to ensure there are no ‘Open’
appointments left on the schedule. Any ‘Open’ appointments are to be followed up,
actioned and processed accordingly
 The senior RT or their delegate is to ensure that any faults resulting in machine down
time are recorded in ARIA under the “Unplanned Linac Repair (Downtime)”
appointment type
Section 10 – On Treatment Reviews
This section guides the clinical staff in the workflow related to the Treatment Review booked
in ARIA
10.1 Roles and Responsibilities

10.1.1 Nursing Staff
 Co-ordinating Treatment Review Clinical Files
 Monitoring and updating patient Check In Status for Treatment Reviews/Treatment
Delivery (as appropriate)
10.1.2 Radiation Oncologists

 Monitoring the ARIA schedule to determine patient arrival for Treatment Review
 Setting the status of available Treatment Review appointments to In Progress, and then
Completed once having seen the patient
 Completing ARIA Journal entries at the time of each Treatment Review
10.1.3 Radiation Therapists

 Reviewing the Radiation Oncologists Journal Note after the patients Treatment Review
and initiating any follow-up action.
10.2 Patient Check-In

10.2.1 Patient Arrival
Upon arrival, each patient will check in at the Reception Counter using the barcode scanner.
This will check the patient in for their first appointment of the day whether it be a Treatment
Review or Treatment itself
 Patients will report to the Nursing Station for all Treatment Reviews. Nurses will
manually Check-In each patient in ARIA if needed
 If one area, treatment or reviews, is either behind or ahead of schedule, staff may
suggest that the patient be taken for their second appointment first to minimise their
waiting time within the department

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10.2.2 Completion of Appointment

 Upon treatment or review completion, staff are encouraged to remind patients to
return to the nurses desk to be checked in for their next appointment
10.3 Patient Review

10.3.1 Viewing the RO’s Review Appointments
The RO will view their schedule using the Appointment Scheduling Workspace
Figure 8: Appointment Scheduling Tabs
Scroll though the list to view the review appointments
 The patients name for which the review is scheduled is clearly displayed within the
appointment
 The appointment time and duration is indicated both on the side of the workspace and
within each appointment.
Figure 2: Appointment Scheduling Agenda View
10.3.2 Reviewing the Patients

10.3.2.1 Patient Arrival
To determine when a patient has arrived for their Treatment Review, the “Checked-in” icon
will be displayed against the appointment in Appointment Scheduling. This patient will be
waiting in the designated waiting rooms.

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 If it is their appointment time and this symbol is not yet present, the patient may not
have arrived yet. Staff are advised to check all patient waiting areas before calling the
patient. If the patient is in the waiting room and has forgotten to check in, re-education
may be required.
 If the check-in symbol is present but the patient cannot be found in the waiting area, the
patient may be attending an unscheduled appointment such as a dietician. Alternatively
the appointment may have been accidently checked-in by a staff member.
10.3.2.2 Commencing the Review

At the commencement of the appointment the status needs to be set to “In Progress” to
indicate to other staff that the patient is currently in clinic undergoing their review.
 To set the review appointment In Progress:

o Right-click on the patient’s appointment
o Select Set Appointment Status
o Select In Progress
Figure 39: Setting an Appointment In Progress
All information regarding a patient’s treatment progress including fraction number, dose
delivered and diagnosis can be found in the Patient Manager workspace of ARIA.
10.3.2.3 Adding a Journal Entry

From each Treatment Review a Journal Note entry must be recorded for all patient
interactions.
 To add a Journal Note

o Navigate to Patient Manager
o Select the Journal Tab
o Select New
o From the Type drop down menu at the bottom, select the most appropriate staff
group (Radiation Oncologist or Registrar)
o Enter the review note in the orange dialogue box
o Click Approve to electronically sign off the Journal note

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Figure 4: Adding a Journal Note
10.3.2.4 Completing the Patient Appointment

Setting the status of the appointment to ‘Complete’ is mandatory. Once the Treatment
Review Appointment is set to ‘Complete’ the correct activity code will automatically be
generated. In addition, a follow up RO note review task will become available for Linac staff
to review and action.
 Upon completion of the patient review, select ‘Back’ at the top of the Patient Manager
workspace. This will return the user to the Appointment Scheduling workspace.
Figure 5: Back Button
 Select the patient’s appointment then select the Complete button at the top.
Figure 6: Complete Button
10.3.2.5 Non-Attendance
If the patient does not attend for their Treatment Review, the appointment must be
cancelled in ARIA.
To set the appointment to Cancelled

 Right-click on the patient’s review appointment, select Set Appointment Status and then
click Cancelled

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Figure 10: Cancelling an Appointment
 The Cancel Appointment Dialog Box appears

o Leave “Do not add Appointment” checked
o Enter an explanatory note describing why the patient did not have their review
o Click Ok
Figure 8: Cancel-Appointment Dialog Box
 At the completion of the day, ensure all appointments have either been completed or
cancelled.
10.4 Linac Staff – Reviewing the RO Journal Note

Completing the RO Note Review Task
A task named “RO Note Review” is attached to each patients Treatment Review
Appointment. This task, displayed in a dedicated User Home Tab named RO Journal Note
Review. This task will only become available once the RO has completed the Treatment
Review Task.
The RO Journal Note Review Tab will display patients from all machines. It is therefore the
responsibility of the machine staff to regularly check this space for their patients as they
become available throughout the day.

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Figure 9: RO Note Review Activity
Radiation Therapists will regularly review the RO Journal Note Review Tab from their User
Home workspace to follow-up/note Journal entries added by the Radiation Oncologist as
part of the treatment review.
To view the Journal Entry

 Select the task named RO Note Review. The Journal workspace will display.
 Identify the relevant RO/Registrar Journal Note. The time and date of the journal entry
is found on the left of the window.
o To aid in identifying the correct note, use the Show Type drop down menu to filter
all journal entries by a particular staff group (e.g. Radiation Oncologist)
 Initiate any follow-up action before selecting Done. Selecting done will mark the task as
complete.
IMPORTANT NOTE: It is imperative that each user is logged in to their own ARIA account to
complete this task. By Selecting ‘Done’ this serves as a formal signoff that all notes have
been actioned and the task is complete
NOTE: All patient journal entries must be reviewed and signed off prior to the subsequent
treatment fraction

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Appendix 1: Appointment Scheduling Symbols

Time Planner Icon Icon Name Meaning
Check-In The patient has been checked in for that
appointment. If the Appointment has been
completed, they may no longer be within the
department.
Series The Time Planner appointment is part of a series
of appointments. You will be able to edit the
series or the individual appointment.
Transport Patient requires transport to and from
treatment. Refer to Patient Manager and clinical
notes for further transportation information.
Appointment Note Appointment contains an appointment note.
Note can be read by hovering the mouse over
the appointment or by opening the appointment
by double clicking.
Complete Treatment has been completed
Partially Complete Treatment has been partially completed.
Cancelled Treatment has been cancelled.
Cancelled Patient Treatment has been cancelled due to the patient

No-Show not attending treatment. Reason should be
documented as per protocol.
In Progress The patient’s treatment is in progress.
Infection Control Patient has an infectious disease. Refer to

Patient Manager and clinical notes for further
details on required precautions.
In-Patient Patient is an In Patient. Refer to Patient
Manager and clinical notes as to which ward.
Questionnaire Appointment has a Questionnaire attached to it
which must be completed prior to completion of
the appointment.
Clinical Directive Patient has given a clinical directive to staff.
Refer to Patient Manager and clinical notes for
further information.
Allergy Patient contains an allergy. Refer to Patient
Manager and clinical notes for further
information.
Checklist Appointment contains a checklist that must be
completed in order for appointment to be
completed.
Clinical Trial Patient is on a clinical trial. Refer to clinical notes
or Activity Capture for further information.

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Section 11 – RT Billing Procedures
This section describes:

 the process for the allocation of Medicare Billing Codes following each occasion of
service of megavoltage external beam treatment (MVT) performed at the Radiation
Oncology Department
 the Billing Quality Assurance (QA) processes to be undertaken by Radiation Therapists
11.1 Alerts
Radiation Therapists are responsible for reviewing billing codes entered in ARIA.
Administration staff will be responsible for checking accuracy of data translated from ARIA
to the third party billing interface.
11.2 Daily Medicare Code Allocation Procedures (Radiation Therapists)

Upon completion of each daily MVT service, the Radiation Therapist will populate, check or
assign the appropriate billing information in the ARIA Activity Capture Dialogue Box from the
4DTC. The following screenshot highlights the fields that must be populated and checked for
each patient, at each occasion of service.
Figure 1: Daily treatment Activity Capture status
Patient Status: for the first fraction ONLY select either New Course or Retreatment Course
from the drop down list using the summarised NSW Health Definitions for Radiotherapy
Data Collection below. For subsequent fractions in the same course the patient status should
be left as Course.

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A course of Radiation Therapy can be defined as either a New Course or a Retreatment

Course. To classify as a Course of External Beam Radiation Therapy, each course must have a
separate
 diagnosis
 ready for care date
 treatment start date
 treatment end date
New Course: the FIRST course of Radiation Therapy delivered to a patient for a new Primary
diagnosis or related metastasis, to which neither have been previously treated with
Radiotherapy in ANY facility.
Retreatment Course: a SECOND course of Radiation Therapy after the patient has received
Radiation Therapy to any site related to the same primary diagnosis. May include:
 metastatic disease if the primary has already been treated with a course of Radiation
Therapy.
 metastatic disease if the primary has not been treated but previous metastatic disease
related to the same diagnosis has been treated.
Important:
‘A patient can receive more than one course of radiotherapy treatment at the same time
(i.e. courses which are simultaneous or which overlap). These courses may have the same or
different ready-for-care dates and the same or different radiotherapy start dates’.
If there is any uncertainty as to the appropriate classification of the course, refer to the
examples cited in the NSW Health Definitions for Radiotherapy Data Collection
documentation.
Patient I/O Status:

Selecting either Inpatient or Outpatient from the pre-defined drop down list.
NOTE: An Inpatient is a patient admitted to The Canberra Hospital only or Medi hotel only.
Patients admitted and transferred from other hospitals e.g. National Capital or Calvary are
considered outpatients for the purposes of our billing. This section will default to Outpatient
unless the Inpatient check box is ticked in Patient Summary in which case the default option
becomes Inpatient.
Date of Service: confirming the date as being the correct date of service provision
Qty: confirm or edit to ensure this value is set to “1” for each entry. This field does not
indicate the quantity of additional fields treated. The hospital procedure code indicates the
number of fields being billed

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Initial Field Procedure Code: confirming or attaching the correct site code for the Initial
treatment field. On the first treatment fraction for each course of the appropriate ‘N’ (new
course) or ‘S’ (subsequent/retreatment course) site code must be selected. Refer to Table 2
for all site specific MBS codes.
Additional Field Procedure Codes: confirming or attaching the correct site code and number
of subsequent fields
Image Verification Codes: selecting the appropriate image verification code (if applicable)
according to the summary of the Medicare Benefits Schedule Book listed below in table 1:
Table 1:
MBS
Code: Suffix: Subgroup 7 RADIATION ONCOLOGY TREATMENT VERIFICATION
15700 Single projection with single or double exposures
Multiple projection Images are taken in more than one plane e.g. orthogonal views
15705 acquisition Treatment must involve three or more fields
When single projections are acquired for multiple sites

Volumetric Computed tomography (such as CBCT)
15710 acquisition
Treatment must involve three or more fields
planar or volumetric IGRT for IMRT, involving the use of at least 2 planar
image views or projections or 1 volumetric image set to facilitate a 3-
15715 IMRT- IGRT dimensional adjustment to radiation treatment field positioning
ADDITIONAL NOTES: Items 15700, 15705, 15710 and 15715:

 Must only be itemised when the verification procedure has been prescribed in the
treatment plan and the image has been reviewed by a radiation oncologist
 Maximum one (i.e. quantity of one) per attendance.
 May not claimed together (i.e. only one item code) for the same attendance.
 As such if more than one item is utilised (e.g. Kv and CBCT) select the highest level code
applicable.
11.3 Medicare Code Quality Assurance Checks

On a weekly basis and at the completion of treatment, the Radiation Therapists must
perform quality assurance on all Activity Capture Data collected during the previous week.
For details on completion of the Activity Capture component of the Weekly Chart see
Section 7 of the External Beam Operations Manual.

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TABLE 2
Medicare Benefit Schedule- RADIATION ONCOLOGY TREATMENT
MBS
Code: Site: Subgroup 3 Megavoltage:
15248N Prostate New Course
each attendance at which treatment is given - 1 field - treatment delivered to primary site (prostate)
15248S Prostate Subsequent Course
each attendance at which treatment is given - 2 or more fields up to a maximum of 5 additional fields
15263 Prostate Additional Field/s (rotational therapy being 3 fields)
15245N Lung New Course
each attendance at which treatment is given - 1 field - treatment delivered to primary site (lung)
15245S Lung Subsequent Course
15260 Lung Additional Field/s (rotational therapy being 3 fields)
15251N Breast New Course
each attendance at which treatment is given - 1 field - treatment delivered to primary site (breast)
15251S Breast Subsequent Course
15266 Breast Additional Field/s (rotational therapy being 3 fields)
15254N Other New Course each attendance at which treatment is given - 1 field - treatment delivered to primary site for diseases
15254S Other Subsequent Course and conditions not covered by items 15245, 15248 or 15251
15269 Other Additional Field/s (rotational therapy being 3 fields)
15257N Secondary New Course each attendance at which treatment is given - 1 field - treatment delivered to secondary site
15257S Secondary Subsequent Course
15272 Secondary Additional Field/s (rotational therapy being 3 fields)
Applies the initial Field and all
additional fields. with IGRT imaging facilities undertaken:
N/ S suffix should be applied at the (a) to implement an IMRT dosimetry plan prepared in accordance with item 15565;
15275 IMRT commencement of a course
Doc Number Issued Review Date Area Responsible Page

V1.0 13-0902 Dec 2015 Dec 2016 Radiation Oncology 85 of 117
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Section 12 – Monthly Accessory Equipment Condition Checks
The aim of the Monthly Accessory Equipment Condition Check is to ensure that accessory
equipment is clean, functional and in good repair to minimise the potential risk of injury to
patients, staff and other stakeholders.
12.1 Alert
All equipment, including that not specifically identified in this procedure is subject to
ongoing inspection on each occasion of use. Any employee who observes a hazard, such as
equipment damage or malfunction, which may lead to injury or incident, must take
necessary action to avoid, eliminate or minimise hazards.
12.2 Procedure
The procedure is to be performed by the Linac Supervisor or delegate on a monthly basis
for all accessory equipment identified in the Accessory Equipment Monthly Condition
Checklist (Checklist).
Each accessory item must be visually inspected for cleanliness, general wear, tear and
damage that may affect function. Inspection must also consider the risk of harm, injury for
patients, staff members and other stakeholders.
Radiation Therapists (RT) must use professional judgement in determining and rating the
condition of accessory equipment as either:
 Good (G) - defined as no obvious damage identified.
 Reasonable (R) - defined as minor wear and tear only.
 Needing Repair (NR) - physical damage detected.
Any wear and tear or damage must be recorded on the Checklist and reported to the Linac
Supervisor who will initiate any necessary follow-up action, either immediate or proposed.
Where an item is rated (R) or (NR) a description of the damage must be recorded in the
Notes Section of the Checklist.
Where an item is rated (NR), the item must be removed from service until repair has been
undertaken or a replacement has been sourced.
The RT completing the Monthly Accessory Equipment Condition Check will:

 Visually inspect each accessory item listed in the Checklist
 Provide a condition rating against each piece of equipment.
 Remove from service any accessory equipment exhibiting general wear and tear that
may lead to injury for patients, staff or other stakeholders
 Report to the Head of Treatment

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o damaged equipment that has been removed from service

o any wear and tear that may indicate an item is approaching end of life, whether
safe or unsafe
 Fill in the date of completion, their initials and sign at the top of the checklist.
 File the completed Checklist in the Monthly Equipment QA (Quality Assurance) Folder
at the Linac
The Head of Treatment will:

 Arrange repair of equipment as required
 Arrange replacement of damaged equipment considered irreparable.
At the end of each calendar year the Linac Supervisor will forward all completed Checklists
to the Head of Treatment for their collation and storage. All records will be stored for three
years before being destroyed.
Linac Accessory Equipment Monthly QA Check List:
Date: …………............. Machine: .......... RT: ………………… Signature: ……………………......

Condition
Accessory Items Notes
G R NR
Linac Couch Top
Inspection of surface and attachment mechanisms for obvious
wear and tear or damage.
LA4: Check functionality of auto positioning electronics panel
at foot of bed
CT Fans - Full
(LA1, 3 & 4) - Half
Contoura Belly Board Board
& inserts
Inspection for obvious
Insert- W
damage upper and
lower surfaces and general Insert- N
wear and tear
Prone-Lok ( Blue)
Includes inspection for damage and general wear & tear
Med Tek Wingboard
Includes inspection of perspex, handles and attachment lugs
for general wear and tear
Med Tek Extended Wingboard
Inc ext’d lokbar (LA1/2, LA3/4)
Includes inspection of perspex, handles and attachment lugs
for general wear and tear
Red Kneefix
Red Footlock

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Condition
G R NR
Med Tec Pronefix (Red)
White Base Plate (WBP)
Iinspection for damage/ general wear & tear - incl locking clips
Med Tec Type-S Extension (LA1, 2 & 3)

and couch interface
Inspection of attachment mechanism, lugs, interlocking
surface and general wear & tear
Med Tec S Overlay (LA1/2 & 3/4)
Includes inspection of attachment mechanism, lugs,
interlocking surface and general wear & tear
Accessory Mount
Inspection for damage and general wear & tear. Inspection of
attachment mechanism
Shoulder Retractor
Includes inspection for damage and general wear & tear -
particularly hand ropes/grips
Breast Board
Includes inspection for damage and general wear & tear -
particularly locking clips
15° Styrox Wedge (2)
Includes inspection for damage and general wear & tear +
includes inspection of covering
Rice Bags
Includes inspection for damage and general wear and tear
Bed Ladder Strap
Includes inspection for damage and general wear and tear;
includes inspection of attachment and security
Yoga Mats
Red/Green handgrip/donut
Inspection for damage and general wear & tear

Pat Slides Grey & white LA1/2
2 slides
LA 3
Inspection for damage and general Gray
wear & tear LA 4
White
Torch x 2 Entrance to bunker
Is in working order and Linac console
located in :
Supports Blue Med Tec ◄
Blue Med Tec █
Blue Med Tec O
Brain Block
Slab Bolus 40cm x 40cm 1.0cm thick

2 @ LA4

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Condition
G R NR
30cm x 30cm 1.0cm thick
Includes inspection for 2 @ LA3
damage and 30cm x 30cm 0.5cm thick
general wear and tear 10cm x 10cm 1.0cm thick
10cm x 10cm 0.5cm thick
Clam Shells
LA1 (one set only)
Iso-Align QA Box and CT Fans
Includes inspection for damage and general wear and tear of
QA box, spirit level, frontpointer and mount & OBI QA cube,
and full and half CT Fans
Magnet
Camera
Med Tec Baseplate & > B’plate
Inserts B’Plate
5
LA 1, 2
LA 3, 4 10
30
Includes inspection for damage and general 3cm spacer

wear & tear 1cm spacer
Med Tec Timo Headrests A

B
C
D
Includes inspection for damage and general E

wear & tear F
Med Tec Silverman A
Headrests B
C
D
E
Includes inspection for damage and general
wear & tear F
Electron Applicators 10*6

10*10
15*15
Includes inspection for damage and general 20*20
wear & tear and presence of standard
25*25
insert
Electron Inserts A1-6
B1-4
C1-4
Includes inspection for damage and general R 1 - 11
wear & tear and presence of standard
insert O - 4, 5, 6, 7, 8,
9, 10, 12
Chemotherapy Spill kit present

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List additional items inspected
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Section 13 – Partial Treatments
This section provides guidance in the situation that a treatment session is unable or should
not be completed as planned in ARIA to ensure the safe delivery and correct accumulation
of dose for each treatment site.
13.1 Partial Treatment of a Plan

Partial treatment of a plan in this section refers to the scenario whereby at least one
treatment field for a particular plan, defined as all beams tied to one prescription, has been
treated and an alteration needs to be made to at least one of the remaining fields in the
plan. This can happen for several reasons, for example errors in ARIA data entry that
should have been captured in our pre-treatment quality assurance procedures or
unknown/unpredictable errors in software or hardware that limit treatment delivery.
 The patient should be closed down from the 4D Treatment Console (4DTC).
 The option the resume should be selected.
Figure 1
 The plan should be opened in ARIA
 THE STATUS OF THE PARTIAL TREATMENT MUST BE RESOLVED AS A FIRST PRIORITY.

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Figure 2
o This is done in plan scheduling

o The affected plan should be selected
o Select the Edit option
o Then Resume Partial and Continue
o This then creates a separate treatment session with the same fraction number that
can be altered to deliver the remaining beams (see appendix 1 for full definition of
the partial treatment options)
 A plan revision can then be created.
 Navigate to the plan parameters or reference point tab where any alterations to the
field/MU/dose can be made to the fields that have not already been treated.
NOTE: Any alterations to the plan should be reviewed by a second fully accredited
Radiation Therapist prior to approval of the plan.
 The revised plan then needs to be planning approved and treatment approved.
 The patient should be closed down from ARIA
 The partial treatment can then be loaded from the 4DTC again.
o The fields that were treated in the original plan/s should still be ticked as
completed.
o The untreated fields on the original plan should now be locked.
o The already treated fields on the plan revision should be locked.
o The only available fields should be those fields in the plan revision that were not
previously treated in the original plan.
Figure 3

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 Once all fields have been delivered the patients should be able to be closed down as
usual.
 Activity capture should auto load as per normal
RADIATION THERAPIST MUST MANUALLY ENSURE THAT PLAN SCHEDULING, SESSION

COMPLETION AND DOSE ACCUMULATION ARE CORRECT PRIOR TO THE NEXT
TREATMENT FRACTION.
13.2 Partial Treatment of a Session

Partial treatment of a session in this section refers to the scenario whereby an entire plan
has been treated, but additional plans are scheduled to the same session that cannot or
should not be treated. For example multiple sites that should not be treated on the same
day or postponement or cancellation of one site in a multi-site treatment, ideally this
scenario should be resolved prior to commencement of beam delivery in plan scheduling.
 The patient should be closed down from the 4D Treatment Console (4DTC).
 The option the resume partial treatment and leave on queue should be selected.
 The plan should be opened in ARIA
THE STATUS OF THE PARTIAL TREATMENT MUST BE RESOLVED AS A FIRST PRIORITY.
Figure 4
o This is done in plan scheduling

o The affected plan should be selected
o The Edit option should be selected
o Then Resume Partial and Continue
o This then creates a separate treatment session with the same fraction number that
can be altered to deliver the remaining beams (see appendix 1 for full definition of
the partial treatment options)
 The scheduling of the plans can then be corrected in the plan scheduling tab.
 These changes need to be saved and the patient closed down in ARIA

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 On the 4DTC the partial treatment should be selected on the queue

o Remove patient from queue
Figure 5
 Activity capture should auto load as per normal, and the treatment session should now
be seen as complete
RADIATION THERAPIST MUST MANUALLY ENSURE THAT PLAN SCHEDULING, SESSION

COMPLETION AND DOSE ACCUMULATION ARE CORRECT PRIOR TO THE NEXT
TREATMENT FRACTION.

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13.3 Appendix 1
Section 14 – BrainLab Couch Transmission Correction
A BrainLab couch top has been fitted to LA4 which is different from the Varian IGRT couch
tops on LA1, LA2 and LA3. Medical Physics have advised that the attenuation of the beam
through the BrainLab couch needs to be accounted for in the delivery of the treatment
plan.
In an emergency this document provides methodology to account for the attenuation of

the beam through the BrainLab couch on LA4. It is the Treatment staff responsibility to
identify appropriate cases for LA4 and apply the following procedure to the required fields.
14.1 Procedure
Calculation must be completed for any beams where 50% or more of the beam’s light field
is passing through the BrainLab couch top to account for the attenuation.
14.1.1 Treatment Staff

14.1.1.1 Calculations with CT data set
 All patients that have a CT scan will be calculated in Pinnacle as per current practice.
 Identify beams with 50% or more of any field entering the patient through the couch
top.
 For these beams, complete the “Calculation Sheet for BrainLab couch top” which can
be found G:\Radiation Oncology\Radiation Therapists\3. Simulation & Planning\4.
Forms and logs\BrainLab Calc sheet. This electronic format has formulas in the
worksheet which will automatically calculate the required MU’s.
 The calculation sheet will be attached to the back of the treatment sheet under the
heading “FSD corrections/ other calculations”. A copy will be imported and
appropriately labelled into the documents workspace of ARIA:
Course_#_Site_BLab_Couch_Calc.
 In the box inside the treatment sheet labelled “MU per Treatment” write the new
couch corrected MU to the right of the primary Linac MU’s. MU’s for LA4 should be
highlighted in orange.

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14.1.1.2 Calculations with no CT data set (Emergency)

 Complete calculation using the Planning Databook “6x Photons MU Table”
 Identify beams with 50% or more of any field entering the patient through the couch
top.
 For these beams, complete the “Calculation Sheet for BrainLab couch top” which can
be found G:\Radiation Oncology\Radiation Therapists\3. Simulation & Planning\4.
Forms and logs\BrainLab Calc sheet (see appendix 1). This electronic format has
formulas in the worksheet which will automatically calculate the required MU’s.
 The calculation sheet will be attached to the back of the treatment sheet under the
heading “FSD corrections/ other calculations”. A copy will be imported and
appropriately labelled into the documents workspace of ARIA:
Course_#_Site_BLab_Couch_Calc.
 Document the MU’s in the treatment sheet and highlight in orange to indicate that the
BrainLab couch factor has been applied.
14.1.2 Attenuation Factors

The attenuation correction factors1 below are used within the electronic Calculation Sheet
for beams passing through the BrainLab couch. As per existing practice, QA processes will
also require a manual check to be undertaken.
MU Correction Factors Gantry 180° → 142° Gantry <142°

Gantry 180° → 217° Gantry >217°
6x 1.043 1.062
18x 1.024 1.035
Example: If monitor units from dosimetric plan = 100 for 6x beam angle 185, then
new monitor units accounting for attenuation through the BrainLab couch
= 100 x 1.043
= 104
14.1.3 ARIA:
Current patients on treatment:
 Complete a plan revision of the original plan
 For the plan including the BrainLab couch top attenuation factor, rename the plan to
include the prefix LA4.
 Change the MU’s on the LA4 plan to account for attenuation through the BrainLab
couch.
 Attach this LA4 plan to the original reference point to ensure the dose accumulation
equals the prescription.
 Planning approve as per normal.
 A second Radiation Therapist must verify the MUs that require correction have been
calculated and correctly transposed in Aria than treatment approve.
On treatment setup, ensure the attenuation factor has been applied appropriately, i.e.:
applied for beams where 50% or more of the beam is passing through the couch top.

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Action any identified corrections prior to treatment delivery. This may include the
application or removal of the attenuation factor.
 Ensure that if the patient is to be treated on another machine, that another plan
revision is created and the MU’s corrected.
 Where there are more than 4 cases that need correction consult with planning to take
over this task.
Case allocation to treatment machines

Skin dose is increased where beams pass through the BrainLab couch top and the BrainLab
couch top is in direct contact with the skin.2,3,4
Cases that may not be treated on LA4 with the BrainLab couch top:
 Single fractions – when beams are entering the patient through the couch top
 Supine rectum
 Supine chest patients with posterior lesions
 SABR
Cases that can have treatment on LA4 BrainLab couch with the attenuation factor applied
for required beams:
 Supine Cervix/ Endometrium/Gynae
 Chest cases – (Note: excluding those with majority of weight and beams passing
through the couchtop.)
 Three field breast
 Tangent fields breast
 4 field breast
 Breast boost
 Prostate
 Rectum- prone
 Cervix on belly board
 Head and Neck
 Brain
 Ant and post palliative- not single fraction
 Post palliative – not single fraction

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14.2 Calculation Sheet for BrainLab couch top

Calculations to account for attenuation of beams passing through the BrainLab couch top
The BrainLab couch top transmission factors are based on beam energy.
Calculation sheet for BrainLab couch top
6MV Gantry 180o → 142o / Gantry 180o→217o Factor = 1.043

Gantry Original New MU's for
Beam Name Angle MU's LA4
0.0
0.0
0.0
6MV Gantry < 142o / Gantry > 217o Factor = 1.062

0.0
0.0
0.0
18MV Gantry 180o → 142o / Gantry 180o → 217o Factor = 1.024

0.0
0.0
0.0
18MV Gantry < 142o / Gantry > 217o Factor = 1.035

0.0
0.0
0.0
Section 15 – DIBH- Treatment Technique
This section describe the steps to deliver treatment to a left breast patient using the Deep
Inspiration Breath Hold (DIBH) technique

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15.1 Daily QA on the Linac for Treatment of DIBH Patients

A Daily QA checklist should be completed before treating any DIBH patients on the Linac.
See appendix A.
1. Ensure the following equipment is present on the linac:
 The HDMI cable from the internal cable cupboard
 Video goggles
 Marker block
 PLOX USB recharge station
 Daily QA checklist
2. Switch on the power to the RPM camera (inside the internal cupboard with HDMI
cable)
3. Connect the Gating Goggles into the extension HDMI cable
4. Plug in the micro USB into the battery pack for the goggles (not available yet)
IMPORTANT: The goggles must be switched on when the PC shows the loading windows
screen during boot-up. To switch goggles on, press the menu button on the goggles
controller box/battery (see figure 1). A blue light on the controller box will indicate that the
video goggles are switched on. The goggles will switch off after 1 minute if no input is
detected. See trouble shooting for more information.
5. Turn on the RPM PC and log into Windows

6. Once the RPM PC has logged on, check that the goggles are connected by:
 Press the menu button on the controller box again.
 Press the menu button on the controller box again.
 Select “CTRL + ALT + Z” (no need to hold)
 The arrow cursor will turn into a cross shape
 Drag the cursor over any region of the screen and see if this can be visualised
through the video goggles.
7. Once all the equipment is on and functioning correctly, the QA process is complete. Fill
out the Daily DIBH QA checklist and continue.
15.2 Preparing the RPM System

1. Select the correct patient
2. Select the patient’s reference session (labelled as ‘ref’)
IMPORTANT: Verify patient I.D. between 4DCT, RPM computer, and patient treatment
sheet
3. The RPM system will automatically enter “planning mode”. To enter treatment mode,
press ‘Stop’ on RPM/gating computer.
4. Ensure gating key is turned on, and beam hold is glowing yellow.

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Figure 1
15.3 Preparing the Bed for the Patient

1. Place the lock-bar at the 0 index level
2. Ensure that the slider bar has NO OFFSET (unless otherwise indicated in the patient’s
treatment sheet) and is firmly fastened
3. Place the Breast Board on the lock-bar and follow the setup instructions to set the
correct Breast Board fittings for the patient
a) Breast Board Incline
b) Left Arm Position
c) Right Arm Position
d) Head Rest
e) Butt Stop
4. Place the KneeFix (KF) or other listed positioning devices inferior to the buttstop
5. Place a folded sheet down over the Breast Board
15.4 Setting Up the Patient

1. Ensure the couch lateral is set to 0.0
2. Have the patient climb onto the Breast Board. With their hands placed on either side
of their hips ask the patient to centre themselves on the Breast Board.
a) If the patient has difficulty climbing onto the Breast Board, provide them with a
stool to assist them
3. Before lying down, have the patients place their hands straight out in front of them
and then lie down in a controlled manner keeping the sheet under the patient
flattened, and using the Tiger Tail rope if necessary.
4. Mark on the required measurements from the setup instructions;
a) Reference Tattoo
b) Post Edge Levelling Tattoo
c) Junction Tattoo
d) FB Medial Edge (If not midline at Reference Level)
e) DIBH Medial Edge (If not midline at Reference Level)
f) FB Post Edge (If not Post Edge Tattoo at Reference Level)
g) DIBH Post Edge (If not Post Edge Tattoo at Reference Level)

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5. Place the Gating Goggles on the patient

a) They made need assistance in focusing the screens. Use the sliding bars on the top
and bottom of the lenses to do this
6. Keeping the couch lateral at 0.0, move the couch long to the Up The Bed measurement
listed in the setup instructions. Check that the Reference Tattoo is within a 0.5cm
Tolerance Sup or Inf.
a) If the Reference Tattoo is outside this tolerance, have the patient move up or down
the bed as required.
b) Having the patient take in a deep breath, then exhale and relax can help achieve
this after they have wriggled.
7. Keeping the couch lateral at 0.0, straighten the patient through midline to the sagittal
laser
a) If the patients midline is not running through the sagittal laser, use the sheet
underneath the patient to move them to the centre of the Breast Board
b) If both therapists are unable to move the patient using this method, ask the patient
to move themselves in the appropriate direction
c) Check that midline of the KneeFix is also aligned through the laser
8. At the Reference Tattoo, set the Rotation FSD. Ensure that the Post Edge Tattoo is
aligning in BOTH the Sup/Inf and Ant/Post Directions. If this is not the case, roll the
patient accordingly.
a) Rotate the patient to match ipsilateral tattoo with the laser, re-setting the AP
rotational FSD.
b) Ensure that after rolling, midline in the centre of the bed has not been affected. If
so, move the patient back to midline before continuing.
c) Shoulder position can often cause a discrepancy in the Sup/Inf positioning of the
Post Edge Tattoo
Figure 2
9. If the patient is having their Supraclavicular Fossa or Axilla treated, turn their head
according to the measurements in the setup instructions. Ensure that BOTH the
Reference and Post Edge Tattoos still align.
10. With the patient straight and level, mark on the Marker Box location in midline from
Reference Tattoo. Place the INFERIOR EDGE of the Marker Box on this mark in midline.
11. Move the couch long Sup, according to the Junction tattoo measurement in the setup
instructions, to assess Junction Tattoo location. The tattoo should align in the Sup/Inf
Direction.

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a) If this is not the case, the shoulder position and/or rotation will need to be
assessed and altered as required.
b) Ensure that when adjusting the shoulder position that you are not just moving the
skin to match.
12. Move back to Reference Tattoo.
15.5 Setting Up the Patients DIBH on the RPM

1. On the RPM system, select Treat
Figure 3
2. The session’s settings should be set to auto record, however the record button can
also be selected.
15.6 Setting Up the Patient for Treatment

1. At the Reference Tattoo, set the FB FSD (Free Breathing FSD) measurement from the
setup instructions
2. Move digitally left as per the Isocentre instructions in the setup instructions.
a. Check that, at the CCP position, the FSD is within 1.0cm of the measurement listed
in the setup instructions
3. Move digitally Sup as per the Isocentre instructions in the setup instructions.
a. Check that the Junction Tattoo aligns in the Left/Right direction within 0.5cm and
is the correct distance in the Sup/Inf direction as per the setup instructions, again
within 0.5cm.
b. If this is not the case, this is an indication that the shoulder is in the incorrect
position, and the patient may require resetting up.
c. Ensure that the Anterior FSD at the Isocentre is within 1.0cm of the FB FSD in the
setup instructions.
4. After the iso position is set, track the patient’s normal breathing by selecting the
“treat” button
a. Ask the patient to breath into the blue line and hold.
b. Ask the patient if this feels correct for them.
c. Ensure that the ISO FSD during deep inspiration is within 1cm of the planned FSD
5. Move the Gantry to the Medial Beam, ensuring that the contra-lateral arm is clear of
the gantry as it rotates.

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a. Ensure that the FB ME is within 0.5cm of the measurement in the setup

instructions.
b. Have the patient take in a breath to the blue line and hold. Check that the DIBH
ME is within 0.5cm of the measurement listed in the setup instructions. Both of
these measurements should be in the same direction (i.e. both to the left, or right
of their respective marks).
c. Take note of these, but do not take action on these until you have assessed the
Lateral Tangent
d. At DIBH assess the Inferior coverage and the overshoot, looking for at least 1cm of
coverage inferior to Breast Tissue and for 2cm of anterior overshoot.
6. Move the Gantry to the Lateral Beam, ensuring that the Gantry is clear of the couch
and the patient as it rotates around. If a PAx field is present, check that the Gantry has
plenty of clearance to reach 180 or 180E. Move back to the Lateral Tangent.
a. Ensure that the FB PE is within 0.5cm of the measurement listed in the setup
instructions.
b. Have the patient take in a breath to the blue line and hold. Check that the DIBH PE
is within 0.5cm of the measurement listed in the setup instructions. Both of these
measurements should be in the same direction (i.e. both to the left, or right of
their respective marks).
c. At DIBH assess the Inferior coverage and the overshoot, looking for at least 1cm of
coverage inferior to Breast Tissue and for 2cm of anterior overshoot.
d. With the information from the ME and PE positioning, refer to appendix B for
problem solving patient setup rotation.
7. Rotate the Gantry to the SCF Field (if applicable) and assess that the field light matches
the planned field on skin.
8. Rotate to the Medial Tangent and assess that the Medial Edge is now appropriate.
a. If not, then use Table 1 in trouble shooting for breast setup.
9. Bring out the EPI panel at the Medial Tangent
a. Record the EPI Offset values and enter these into ARIA.
10. Inform the patient you are about to leave the room, and that you will be talking to
them through the microphone.
a. Let them know that the Breath In instruction will sound like “Ok ___ Take in a
deep breath to the Blue Line and Hold”
b. Let them know that the Breath Out instruction will be “Ok ___ Breath Normally
and relax”
c. Ensure that the in-room music is quiet enough that the intercom can be heard.
d. Let them know that if they cannot hold their breath during a beam that the
radiation will automatically cut off if they exhale.
11. Perform the pre-treatment checks;
a. Correct Patient on the bed
b. Correct Isocentre
c. Correct Medial Edge
d. Correct Post Edge
e. Bolus/No Bolus
12. Leave the room.

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15.7 Delivering the DIBH treatment

1. In Aria, there is a gating tick box for each treatment beam. To tick this box, the
therapist must have:
a. Checked that the correct patient is loaded on RPM
b. Confirmed that the “enable gating” button has been selected
NB: If this is not selected, the beam will stay in beam hold mode and not deliver
any monitor units.
2. At the clinac console, prepare the first treatment beam until the key is ready to be
turned.
3. Ask the patient to take a deep breath. Once the patient reaches their breath hold, (i.e.
the yellow bar turns green in the blue section) turn the key and press beam on.
4. Inform the patient over the microphone when the beam is half way through delivery.
5. Once the beam has completed, over the microphone ask the patient to relax and
prepare for the next treatment beam.
6. Continue this process until all beams are delivered.
15.8 DIBH Trouble shooting technical issues

16.8.1 Goggles not working:
1. Open the Matrox PowerDesk HF application by double clicking on the “M” icon at
bottom right of screen (indicated by arrow)
2. The Matrox main menu will appear. Click on “Multi-Display Setup”
3. Select “2 displays, Clone mode”, then restart the computer with the goggles switched
on
4. After restarting, the goggles will show a copy of the main monitor view
5. Again, open Matrox “Multi-Display Setup” and select “1 display + 1 feature display”
then restart the computer again

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6. Ensure the goggles are switched on during computer boot up, especially when “Varian
loading” is being displayed (the computer must recognise the goggles as a second
monitor)
7. Then press Ctrl + alt + Z simultaneously, then click and drag to select a region to be
visualised through the goggles
8. The region selected needs to meet a minimum/maximum resolution. If this is not met,
then occasionally nothing will display on the goggles. If this occurs, simply reselect an
area to display, ensuring that a smaller or larger region is chosen
9. This process can be repeated at any stage to modify what the patient is able to see
through the goggles, but it is important to ensure the goggles are working before
getting the patient into the treatment room
10. If the goggles still don’t work, repeat steps 1-7 and consult a DIBH super user
16.8.2 Camera not tracking:

1. Ensure gating camera + small screen are switched on
2. Ensure the camera is not detecting an unwanted reflection (hint: patient jewellery or
linac?)
15.8.3 RPM session options incorrect:

1. Click “Session Options” in the bottom left corner
2. Under the “Gating” tab, under “breathing type”, select “breath-hold”
3. Under the “Audio” tab, select “Disable”
4. Under the “Visual” tab, select “Enable” and set motion range as “breath-hold”
5. To set these settings as default, password is “RespGate”

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15.8.4 DIBH Technical Fault workflow
Has a DIBH super user been contacted?

STAGE 1
STAG
YES – (but, still have the fault) NO – contact any of the following: Trish
Has radiation Banyer, Brett Fittler, Janelle Hawkins,
engineering/physics been Wes Thom, Brendan Donovan, Amy
contacted? Murphy, Leah Oliver, Monica Hunter, or
Deb Tucker
a DIBH super user?
YES – (but, still NO – contact any of the following
have the fault) Rad Engineering: STEVE – x42239, 0451055891; Erik – x43614,
0435406420
Physics: Helen Gustafsson x Jonathon Lee x
Can the patient be treated on an alternative Linac fitted

STAGE 2 with RPM (i.e.LA1, LA2 or LA3)?
YES – NO –
Treat patient and consult with Can the patient be sent away for a period
RadEng/RadPhys for fault resolution of time whilst the fault is resolved and
timeframe on the affected Linac treated later ON THE SAME DAY?
a DIBH super user? a DIBH super user?

YES - consult with RadEng/RadPhys to
establish a timeframe and rebook appt.
Contact HOT/DCRT to assist in decision
making
a DIBH super user?
STAGE 3 NO –CONTACT RO if patient will miss a planned treatment fraction

Can the patient be treated the following available treatment day?
YES – Treat patient the NO – Contact RO and planner;

following day. Move any appt consider the possibility/need of
times to allow for repairs as replanning as free breathing plan if
necessary. patient is going to miss more than
two days of treatment
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Appendix A
This Daily QA checklist is used to unsure the RPM system and video goggles are functioning
correctly, and should be completed daily before simulation or treatment of any DIBH
patients.
Task Checks Completed Comments
(tick)
Hardware  Video Goggles
Locate all DIBH equipment
(including adequate battery  HDMI cable in-room
charge)
 Breathing phantom & marker box
 Plox recharge station
Gating Camera  Switch on gating camera power

(grey box)
Goggle Setup  Connect goggles to HDMI cable in
Connect all devices for treatment room
viewing content through  Ensure goggles are also switched on
goggles and then turn on RPM computer
 Select zoom region [Ctrl + alt + Z]
and check goggles are working
(Please turn over for
troubleshooting)
RPM Software  RPM software is tracking 2 dot
1. Open patient: “a__QA marker box on breathing phantom
Daily DIBH QA”
2. Add new reference  Record new reference session
field as today’s date
3. Track
 Settings are correct for DIBH
(Please turn over for
troubleshooting)
Enable Gating  Locate switch key for gating box
(linac only)
Switch key on gating box

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Appendix B Breast Setup Problem Solving

ME PE Solution Visual
Position Position
Contra- Post Lower the couch
Lateral vert by a
MAXIMUM of
0.3cm
Contra- On Rotate patient

Lateral towards contra-
lateral half the
required distance
Lower the couch
vert the remainder
of the distance, by a
maximum of 0.3cm
Check the ATT is
within 0.5cm
Contra- Ant Rotate the patient
Lateral towards contra-
lateral
Check the ATT is

within 0.5cm
On Post Rotate patient

ipsilaterally half the
required distance
Lower the couch

vert the remainder
of the distance, by a
maximum of 0.5cm
Check the ATT is
within 0.5cm

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On Ant Rotate the patient

towards contra-
lateral by half the
required distance
Raise the couch vert

the remainder of
the distance, by a
maximum of 0.3cm
Check the ATT is
within 0.5cm
Ipsi- Post Rotate the patient
Lateral ipsilaterally
Check the ATT is

within 0.5cm
Ipsi- On Rotate patient

Lateral ipsilaterally half the
required distance
Raise the couch vert

the remainder of
the distance, by a
maximum of 0.3cm
Check the ATT is
within 0.5cm
Ipsi- Ant Raise the couch
Lateral vert by a
MAXIMUM of
0.3cm

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Section 16 – Dosimetry Interlocks
This section provides guidelines to ensure Radiation Therapists are able to deliver services
to patients efficiently without undue delays caused by common dosimetry Interlocks during
treatment delivery.
16.1 Background
After review of common dosimetry interlocks recorded for LA2 and LA3, dosimetry
interlocks that require medical physics intervention and those that can be cleared by
qualified RTs were determined and documented using the following methodology:
1. The log books from LA2 and LA3 were reviewed to determine the most common
dosimetry interlocks that have occurred. Data of LA-1 and LA-4 were not collected as
LA-1 is out service and LA-4 recently commenced clinical operation and did not have
sufficient data.
2. There were six main combinations of dosimetry interlocks identified as shown in Table
1 (see Appendix 1).
3. Most dosimetry interlocks are minimally recorded in the Log Book as “Dosimetry
interlocks” and do not capture required interlock information.
4. During data collection, the XDRS interlock was found to appear with photon energies at
gantry angles between 240o-280o.
5. Dosimetry Interlocks, their description and options which can be cleared by qualified
Radiation Therapists were documented in Table 2 (see attachment 2).
16.2 Alerts
Qualified Radiation Therapists are authorised to clear dosimetry interlocks as described in
Table 2. Interlocks other than those specified in Table 2 are to be addressed by a Radiation
Engineer in the first instance. The Radiation Engineer will contact a Medical Physicist as
appropriate.
1. If any dosimetry interlock or combination of dosimetry interlocks described in Table 2
appears more than once (>1) during treatment beam-on then do not clear it and refer
to MPRE in the first instance.
2. If a dosimetry interlock described in Table 2 occurs more than twice (>2) in any one
day, MPRE must be contacted prior to proceeding with treatment delivery.
3. DOS2 and DSFA are the most critical Dosimetry Interlocks (which are highlighted with
red in Table 2). If DOS2 or DSFA Interlocks appear and terminate the beam, report to
MPRE and do not proceed with any treatment until the machine is cleared for use by
Medical Physics.
4. If the DOS2 interlock appears during the calibration cycle, it may be overridden by
using the dosimetry password. If the DOS2 interlock occurs more than two times for
the same patient, you must contact Medical Physics before proceeding with the
treatment.

CHHS16/204
16.3 Procedures
All dosimetry interlocks must be recorded in the Linac Fault/Log Book. As a minimum the
following must be recorded for each entry.
1. The dosimetry interlock or combination of dosimetry interlocks;
2. Collimator angle,
3. Gantry angle,
4. Beam energy.
An appropriately experienced Radiation Therapist at Level RT2.1 and above can clear the
dosimetry interlock or a combination of dosimetry interlocks described in Table 2 with the
current dosimetry password.
The current dosimetry password will be advised by Medical Physics or Radiation

Engineering.
A Dosimetry Interlock described in Table 2 may only cleared by the designated Radiation
Therapist in reference to detailed alerts.
Table 1 Common Dosimetry Interlocks: Log book recorded events (LA-2 and LA-3)
Sr. # Interlocks LA-2 LA-3

1 CKFA-EXT-Time-DOS1-Door-ISPN* 4 14
2006 to 2012
2008 to 2012
2 XDRS 122 69
3 XDRS-EXT-RVBP-IPSN-MLC-DS12* 24 29
4 CLFA-ION1-ION2-EXQ1-EXQ2-EXQT-LVPS-XDR1 15 70
5 Dosimetry Interlocks (excluding DOS2 and DSFA) 19 12
6 DS12 5 11

CHHS16/204
Table 2 Dosimetry Interlocks Authorised for Clearance by Radiation Therapists

Prepared by Medical Physics in consultation with Radiation Engineering and Radiation
Therapists
DOSIMETRY AUTHORITY TO
SR. # DESCRIPTION
INTERLOCKS CLEAR
1 CKFA Calibration Cycle Interlock Yes
2 CKTO Check Time Out Interlock Yes
3 CLFA Calibration Failed Yes
4 CLTO Calibration Cycle Took Too Long Yes
5 DOS2* Dosimeter Interlock No
6 DS12 MU1 and MU2 are not Matching Yes
7 DSFA Actual Dose is Greater than set Dose No
8 ENSW Energy Switch Interlock Yes
9 EXQ1H Radial Symmetry Tolerance Interlock (2%) Yes
10 EXQ2H Transverse Symmetry Tolerance Interlock (2%) Yes
11 EXQTH Total Asymmetry (2%) Yes
12 ION1 Radial Ion Chamber Interlock Yes
13 ION2 Transverse Ion Chamber Interlock Yes
14 LVPS Low Voltage Power Supply Interlock Yes
15 SYM1L Radial Symmetry Yes
16 SYM2L Transverse Symmetry Yes
17 XDP1 Radial Dose Per Pulse Interlock Yes
18 XDP2 Transverse Dose Per Pulse Interlock Yes
19 XDR1 Radial Dose Rate Yes
20 XDR2 Transverse Dose Rate Yes
21 XDRS Servoed Dose Rate Yes
Peak Current Interlock (Target and Ion
22 YLDL Yes
Chambers)
Note:
* If the DOS2 interlock appears during the calibration cycle then it can be overridden
by using the dosimetry password.

CHHS16/204
Section 17 – Aria Tolerance Tables
This section includes the acceptable variance tolerance tables for the treatment couch and
Linac treatment parameters specific for each treatment technique.
17.1 Alert
Professional judgment should be used to guide decision making in relation to the
appropriate tolerance table on a case by case basis.
There are circumstances that an auto gantry movement is deemed unsafe. If there is any
uncertainty between the couch and Linac clearance, during the V1 check stage (Section 5) of
the External Beam Operations Manual the checker should ensure a Manual Gantry
movement is applied until after the initial treatment and all angles have been physically
checked. During the V2 verification check or any subsequent treatment the treatment
tolerance table maybe amended.

CHHS16/204
17.2 Aria Tolerance Tables

CHHS16/204

CHHS16/204
Related Policies, Standards, Procedures, Guidelines and Legislation
Policies
CHHS Patient Identification and Procedure Matching Policy
Work Health and Safety Policy DGD 12-036
Standards
Australian Commission on Safety and Quality in Health Care (2006). Ensuring correct
patient, correct site, correct procedure; http://www.safetyandquality.org/
Standard 12, Radiation Oncology Practice Standards 2011
Planning for the Best, Tripartite National Strategic Plan for Radiation Oncology 2012-2022
Radiation Oncology Practice Standards 2011
Planning for the Best, Tripartite National Strategic Plan for Radiation Oncology 2012-2022
Legislation
Radiation Protection ACT 2006
Radiation Safety Policy for ACT Government Health Directorate
References
1. ACPSEM Position Paper Recommendations for the Safe Use of External Beams and
Sealed Brachytherapy sources in Radiation Oncology, Ser No 157, ISSN 0158-9938
2. Iso-Align: Reference Guide, Civco, USA, 2011
3. Varian Medical Systems:
a. Trilogy Tx Instructions for Use, P/N 1000028159-08 September 2009
b. On-Board Imager (OBI) Reference Guide Advanced Imaging, P/N 13501007RO1B; Vs
1.4, April 2008
4. Radiation Therapy – Treatment – Use of LA4’s Robotic Couch Top for Standard
Treatment
5. NSW Health –New Definitions for radiotherapy data collection in NSW
www.health.nsw.gov.au
6. Varian Medical Systems Activity Capture Reference guide (June 2006)
7. Bell, L, Shakespeare, T & Willis, A 2008, ‘Importance of daily electronic portal imaging in
radiotherapy’, Journal of Medical Imaging and Radiation Oncology, vol. 52, no. 4, pp.
414-418.
8. eviQ Treatments Online 2014, Radiation Oncology, Breast, Invasive Breast Cancer,
Adjuvant Nodal Irradiation, EBRT, Cancer Institute NSW, viewed 31 July 2014,
https://www.eviq.org.au/Protocol/tabid/66/categoryid/178/id/1282/Radiation+Oncolo
gy%2c+Breast%2c+Invasive+Breast+Cancer%2c+Adjuvant+Nodal+Irradiation%2c+EBRT.a
spx
9. eviQ Treatments Online 2014, Radiation Oncology, Palliation, Spinal Cord Compression
(SCC), External Beam Radiotherapy, Cancer Institute NSW, viewed 31 July 2014,

CHHS16/204
https://www.eviq.org.au/Protocol/tabid/66/categoryid/190/id/296/Radiation+Oncology
%2c+Palliation%2c+Spinal+Cord+Compression+(SCC)%2c+External+Beam+Radiotherapy.
aspx
10. Fein, D, McGee, K, Schultheiss, T, Fowble, B & Hanks, G 1996, ‘Intra- and interfractional
reproducibility of tangential breast fields: a prospective on-line portal imaging study’,
International Journal of Radiation Oncology Biology and Physics, vol. 34, no. 3, pp. 733-
740.
11. Michalski, A, Atyeo, J, Cox, J & Rinks, M 2012, ‘Inter- and intra-fraction motion during
radiation therapy to the whole breast in the supine position: A systematic review’,
Journal of Medical Imaging and Radiation Oncology, vol. 56, no. 5, pp. 499-509.
12. Middleton, M, Rolfo, A, Medwell, S, See, A, Wong, J, Joon, M & Lynton-Moll, M 2006,
‘Online versus offline corrections: operation or evolution? A comparison of two
electronic portal imaging approaches for locally advanced prostate cancer’, The
Radiographer, vol. 53, no. 1, pp. 24-28.
13. Russo, G, Qureshi, M, Truong, M, Hirsch, A, Orlina, L, Bohrs, H, Clancy, P, Willins, J &
Kachnic, L 2012, ‘Daily orthogonal kilovoltage imaging using a gantry-mounted on-board
imaging system results in a reduction in radiation therapy delivery errors’, International
Journal of Radiation Oncology Biology Physics, vol. 84, no. 3, pp. 596-601.
14. Smith, R, Bloch, P, Harris, E, McDonough, J, Sarkar, A, Kassaee, A, Avery, S & Solin, L
2005, ‘Analysis of interfraction and intrafraction variation during tangential breast
irradiation with an electronic portal imaging device’, International Journal of Radiation
Oncology Biology Physics, vol. 62, no. 2, pp. 373-378.
15. On target: ensuring geometric accuracy in radiotherapy. The royal college of
Radiologists/ Institute of Physics and Engineering in Medicine, Society and College of
Radiographers, 2008
16. Using Portal Vision With 4D Treatment Console, Training Solutions 2008, Varian Medical
System, USA, 2008
17. OBI 1.5 Therapist Operations rev 3.1.0 , Varian Medical Systems, USA 2006
18. OBI 1.5 Advanced Imaging Reference Guide, Varian Medical Systems, USA, March 2013
19. OBI 1.5 Therapist Operations rev. 3.1.0, Varian Medical Systems, USA 2006
20. Varian Medical Systems. (2012, November). ARIA 11 Offline Review Workbook.
Retrieved from MyVarian.
21. Christopher F Njeh, Jason Parker, Joseph Spurgin and Elizabeth Rhoe. A validation of
carbon fiber imaging couch top modelling in two radiation therapy treatment planning
systems: Philips Pinnacle3 and BrainLAB iPlan RT dose, , Rad. Onc 2012, 7:190
22. Jan K.H Seppala, Jarmo A.J Kulmala. Increased beam attenuation and surface dose by
different couch inserts of treatment tables used in megavoltage radiotherapy. J Appl
Clin Med Phys. 2011: Vol 12, No 4.
23. Christopher F Njeh, Timothy W Raines, Mark W Saunders. Determination of the photon
beam attenuation by the BrainLAB imaging couch:angular and field size dependence. J
Appl Clin Med Phys. 2009: Vol 10, No 3
24. Memo from Medical Physics and Radiation Engineering - LA4 MU Correction Factors for
the BrainLab Couch. Dated 28th August 2013
25. The dosimetry interlock information was collected from the Log Books provided by the
Radiation Engineering Department.

CHHS16/204
26. Appendix F, “Trilogy Tx Instructions for Use”, Varian Medical Systems, P/N 100028159-
08
Definition of Terms
ATT: Above Table Top

CBCT: Cone Beam Computed Tomography
CLNG: Couch Long
CTV: Clinical Tumour Volume
DIBH: Deep Inspiration Breath Hold
FSD: Focal skin distance
HOP: Head of Planning
HOT: Head of Treatment
MEB: Motion Enable Button
MLC: Multi-leaf Collimator
MVT: Megavoltage Treatment
OAR: Organ at Risk
PTV: Planning Tumour Volume
RO: Radiation Oncologist
V1: Pre-treatment Verification
V2: Day two verification check
Search Terms
Radiation Therapy, External Beam Radiation, Radiation Therapists
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically
for its own use. Use of this document and any reliance on the information contained therein by any third party
is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
Date Amended Section Amended Approved By

Eg: 17 August 2014 Section 1 ED/CHHSPC Chair


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CHHS16/204

Canberra Hospital and Health Services

Doc Number Version Issued Review Date Area Responsible Page

1.8.3 Faulty Accessory Equipment ................................................................................... 19

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Section 5 – Pre-Treatment Quality Assurance Checks ............................................................. 45

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7.10.4 Finalisation of the RT- Weekly Chart Check Encounter ........................................ 67

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11.3 Medicare Code Quality Assurance Checks .................................................................. 84

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17.2 Aria Tolerance Tables ................................................................................................. 113

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Section 1 – Treatment Area General Information

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1.2 Radiation Therapists Staff Organisation

The Head of Treatment is responsible for duties such as:

LINAC staffing normally comprises:

The LINAC Supervisor is responsible for duties including:

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1.3 Radiation Therapist Responsibilities

1.4 Linac Start-up and Handover

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1.5 Daily Machine Geometry Quality Assurance

1.6 Treatment Delivery

1.6.1 Starting a New Case

1.6.2 Team Work Guidelines

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1.6.3 Notes on Patient Set-Ups

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The Radiation Therapist switching on the LINAC will:

The Radiation Therapist seated at the 4DTC will:

1.6.4 Billing Procedures

1.6.5 Verification Images

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1.6.6 Weekly Chart Checks

1.6.7 Patient Reviews

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1.6.8 Course Completions

1.6.9 Close of Business

1. 6.10 Quality Assurance

1.6.11 Personal Stabilisation Devices

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1.6.12 Other Matters

1.7 Annual Business

1.8 Fault Documentation

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1.8.1 LINAC Faults preventing the progression of treatment

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1.8.2 LINAC Faults not preventing the progression of treatment

1.8.3 Faulty Accessory Equipment

1.9 Machine Breakdowns

If the breakdown occurs during a treatment, then:

Doc Number Version Issued Review Date Area Responsible Page

 The Head of Treatment will:

Doc Number Version Issued Review Date Area Responsible Page

1.10 Transport from Wards, Hospitals & Community

Inpatients at Other Hospitals

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