2008 has seen a nationwide programme of Virtual Environment Radiotherapy Training (VERT) equipment installed throughout England by Vertual and Virtalis, funded by the Department of Health.

This technology is now being made available to the rest of the world, with interest coming from around the globe.  The new systems, which are already revolutionising the way in which radiotherapists are trained, are the result of a collaboration between Vertual, who developed the VERT software, and Virtalis, who supply the integrated visualisation hardware.

VERT IN ACTION

The University of the West of England was the first of 40 English institutions to have its system installed. Jan Chianese, UWE Radiotherapy Programme Leader, said, “Everyone in the department is very excited about the Vertual system, as it will mean students get to grips with the basics of operating these complex tools and get far more practice and gain confidence in a safe setting. I must emphasise that clinical practice in hospital settings will continue to be a critical element of radiotherapy training, but now that students can practise on the VERT system, they will develop familiarity and become better practised with the tools used in the hospitals. This will mean they can concentrate on other skills such as communication with patients which can be difficult to do when faced with a complex piece of machinery for the first time.”

WHAT IS VERT?

Virtual Environment Radiotherapy Training, or VERT, is specialist software designed to offer a vast range of training for radiotherapy students, nurses and existing staff. It was developed by Prof. Roger Phillips and James Ward from the University of Hull and Prof. Andy Beavis of the Hull & East Yorkshire Hospitals NHS Trust. Now VERT is being developed and supplied by a spin out company, Vertual Limited. However, for the software to give the level of realism it was designed to provide, it needs a Virtual Reality (VR) stereoscopic 3D visualisation system. Virtalis is the supplier of the visualisation equipment for the VERT system and is one of the most respected names in medical VR, having created MIST VR, the world’s first laparoscopic VR trainer, in the mid 1990s.

The realistic graphics of VERT provide an excellent alternative to training in operational facilities without the associated cost. Early users of the system report a genuine gain in experience, with 3D visualisation proving to be a powerful tool for showing treatment plans, anatomy and dose distributions. A range of radiotherapy machines, or linear accelerators (popularly known as Linacs), are recreated virtually, namely: Varian, Elekta and Siemens. The beauty of virtual environment based training is that students can have a far greater quantity of experiences than would be possible in a real radiotherapy treatment room. Not only that, there is no risk to patient or equipment and students report feeling more relaxed as a result. In particular, radiotherapy concepts that are difficult to grasp in a classroom setting have been found to be much easier to assimilate thanks to VERT. VERT enables hands-on experience of patient set-up and radiotherapy treatment plans, whether simple or complex, to be loaded into VERT for the simulation of treatment.

Benjamin Roe, UWE Senior Radiotherapy Lecturer said, “The VERT screen takes up an entire wall of a specially blacked out lecture theatre to mimic the setting of a linear accelerator (LA) treatment suite. VERT displays a life-size model of a virtual patient lying on a table with the LA positioned above. The student uses a special controller that is exactly the same as those used in the clinical setting. The student is able to move the table and LA into the correct position using the controls. The radiotherapy beam is illustrated by a virtual light beam that shines onto the area of the patient’s body to be treated. Students put on special 3D glasses so that the entire procedure is simulated in 3D. Another important aspect of the tool is that there is the capability to view the beam entering and exiting the body in cross section – this will prove very useful in training as we can highlight things like the importance of avoiding organs and the spinal column when positioning the LA.”

WHY VERT IS NEEDED

VERT meets a very prescient need. A recent report by the National Radiotherapy Advisory Group (NRAG) in the UK concluded that by 2016 the amount of radiotherapy provided will need to almost double. For this to happen, more trained staff and Linacs will certainly be required. Although 167 new Linacs have been installed, either as replacements or as additional machines, their numbers per million of the UK population remain below several other European countries.  Thus radiotherapy delivery is constrained, as is research and training. In addition, NRAG has reported that insufficient clinical training is a contributory factor to the 35% drop out rate among radiographers. As a result, £5 million of funding was released for the provision of VERT systems in England by the Department of Health.  In 2008, systems have been, and are continuing to be, installed at 10 Universities and up to 45 hospitals and hospital trusts.

All the resource, training and cost issues seen in England apply equally around the world where the increasing demand for radiotherapy treatment is putting services under severe pressure.

VERT therefore solves two problems at a stroke and delivers strong HR and patient benefits:

• – provides safe, realistic training
• – does not tie up useful equipment
• – boosts career fulfilment within the radiography profession and
• – helps professionals and patients understand and communicate the treatment plan and method.

Student reaction to the VERT system has been very positive. Jo Houlding, who is now in her third year at UWE, enthuses, “In year one, a major concern was not having very much, if any, experience on a linear accelerator before going out on placement. Although I didn’t find it hard to get to grips with operating a linear accelerator personally, I know that others took some time to do this, which meant less time was spent learning clinical skills like radiotherapy techniques and patient care. Having VERT will enable students like me to gain knowledge and establish some confidence with the equipment before going out on clinical placement.

“In the second and third years we progress onto more complex treatment techniques. This takes time for us to process the academic principles and then apply them clinically, which is hard in practice as there are many pressures, due to time both in the ethics of having the patient on the bed for too long and with the constant high demand for the machines. By having access to this equipment, there will be more time for us to learn techniques, without feeling this time pressure. It also allows you time to ask questions that sometimes you may not feel able to ask on placement. I really wish this system had been available when I started the course – it’s amazing.”

VERT SYSTEM SPECIFICATIONS

VERT has been designed to work to deliver training on two different levels, depending on teaching methodology, available space and available budget.

The first level is called Immersive VERT- this has been designed for Universities and large training centres where the system is housed in a specially designed immersive auditorium. Utilising dual channel active 3D stereoscopic rear projection at 1:1 scale, a student can walk around the virtual training room during a training exercise. The student’s movement is tracked and his field of view alters as he moves. Alternatively, an instructor can use the entire wall of the room to demonstrate concepts to a classroom of students. 3D images of the virtual radiotherapy treatment room are rear projected, so the trainee/ instructor can walk in front of the screen on a staged area without creating a shadow, making it ideal for both solo training or classroom teaching.

An example of a typical set-up is shown above although room sizes and layouts can vary considerably:

The smaller scale VERT system is called Seminar VERT. Any seminar room or large meeting room would be suitable for installation of this simple, single channel 3D stereoscopic front projection system. Although the principal user is not tracked (tracking is an option), the equipment in the VR room can also still be operated via a real hand control pendant.

Seminar VERT has been developed specially for classroom teaching and radiotherapy clinics. An example room layout is shown here. Typically the room size will vary from 5 x 4.5 metres up to 7 x 6 metres.