colorectal pathway north bristol nhs trust. background colorectal pathway introduced in 2006 shorten...
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Colorectal Pathway
North Bristol NHS Trust
Background
• Colorectal pathway introduced in 2006
• Shorten patient pathway
• Straight to test
• Reduce routes into the system
Reason for Change
• Introduction of CTC
• Confusion about subsequent pathways
• Pathway for elderly
• Pathway for anaemia
• Sub specialist clinics eg anal fissure/prolapse
Reasons for change
• Discovery programme
• We’re told GPs want to refer directly to test
Aims
• To change our pathway in line with NICE guidance and new innovation
• To offer the opportunity for GPs to book direct to test
• To improve patient experience
• To improve early cancer diagnosis
2WW Symptoms
Rectal bleeding with CIBH to looser stool >6 weeks age >60
AGE TEST
60-75 colonoscopy
75-85 CTC
>85 CT with extended oral prep
CIBH to loose/more frequent stools without rectal bleeding >6 weeks age >60
Iron Deficiency anaemia OGD
Rectal bleeding without anal symptoms >6 weeks aged 60 or >
Abdominal or rectal mass
Flexible sigmoidoscopy with PO4 enema
Clinic
and
Referral pathway based on symptoms
Pathway tells you what test to order
We track the patient internally to meet cancer targets
Test shows cancer/significant abnormality
Test is normal or non cancer diagnosis
Back to GP with advice
We triage
We book tests
GP refers as now either to clinic via C&B or TWW referral to cancer office
Option 1 Option 2
We deal with ongoing tests
GP books test or clinic
In addition
• You will always have the option to send to clinic instead of to test
• You can choose CTC over colonoscopy if patient has weight loss as well or you have concerns that the diagnosis may be extra colonic eg ovarian
After selecting your patient then you start by selecting a new request
The book icon will take you to a copy of the guidance on which diagnostic test to pick
These tests are all for colorectal pathways and cant be used for non colorectal 2ww referrals
Click on the relevant test that you want to order, and then it will bring up a text box
The system will ask you a series of questions to validate the request. This is a requirement of the endoscopy accreditation (JAG) and will help the endoscopy unit to plan for the necessary scope
Each box asks you the same questions that are included within the current 2WW form. Therefore it is asking for you to confirm the symptoms.
It will go on to ask you a small number of extra questions. If the answer is outside of the scope of the pathway then it will inform you that the patient is not suitable and recommend another test.
Based on your answer to this question then the system will recommend the suitable bowel prep for the patients to be dispensed by NBT
It is important to note that colonoscopies and CTCs need patients to have bowel prep. Therefore you are required to confirm that the patient is medically fit to receive the bowel prep. NBT will then dispense the prep to the patients.
This page and the following three are series of questions that are key to help endoscopy effectively plan that patients scope. Please answer as fully as possible
NBT will arrange for the test to take place within two weeks of you clicking “continue with request”
The trust will contact you with the outcome of the diagnostic within 48 hours of it being conducted, but is aiming for 24. If the patient has an abnormality then NBT will pick up the care. If not then you will be provided with advice and guidance with the patient discharged back to your care.
3 month reviewreferral CTC reporting clinic pt informed/ meeting CNS
7 days 10 days 31 days
referral Colonoscopy pt informed/ meeting CNS8 days8 days
14 days
old pathway
new pathway
• Pathway changes for the majority of the patients• Improved patient experience• Shorten care pathway• Has taken pressure off of CTC and clinic capacity, enabling a shorter wait for
these elements of the pathway
• Colorectal 62 day cancer performance:January February March80.8% 88.9% 95%
GP feedback
• “the new pathway looks fantastic…simple and understandable which is great for those of us easily bamboozled by multiple pathways from multiple departments”
• “Thank you…the use of ICE is also very welcome, makes the job that little bit easier and every little helps”
• “I have just done my first 2WW colorectal pathway referral via ICE. It is a brilliant system, very straight forward. Well done”
Findings so far
Row Labels January February March April (until 20th) Grand Total
Colitis 1 1 1 3
Colonic finding other than cancer 1 5 2 2 10
Colorectal Cancer 2 1 1 4
Inconclusive examination 1 1
Normal examination 5 16 13 4 38
Polyps identified & removed at endoscopy 1 4 5 1 11
Small polyps, (<6mm polyps), not removed needing therapeutic endoscopy 1 1 2
Other/ outcome not yet captured 4 5 21 30
Grand Total 7 34 28 30 99
Challenges
• Took 6 months to introduce pathway – cost implication for CCGs
• GP uptake has been slower than anticipated
• Rolling pathway out for all colorectal patients
Further information
• [email protected] – colorectal surgeon
• [email protected] – colorectal surgeon
• [email protected] – Assistant General Manager for Surgery