Post on 13-Feb-2017
CNS Alison AndrewsDr Ian Norton
Dept. of GastroenterologyRoyal North Shore Hospital
Expediting Colonoscopy for Patients with a Positive
Faecal Occult Blood Test
AimTo expedite colonoscopy for patients presenting with a
positive Faecal Occult Blood Test (FOBT)
Team membersProject team members:Ian NortonAlison Andrews, CNS
Background• Colon cancer is the commonest cancer in Australia• The Federal Gov. has recently accelerated the rollout of
the National Bowel Cancer Screening Program to 2nd yearly after age 50 by 2018
• This will result in up to 100,000 extra colonoscopies per year in Australia (DoHA – personal communication)
– We anticipate up to 1000-1500 extra colonoscopies on the public system at NSLHD
• Ideally, colonoscopy should be within 30days• 10% of these patients have cancer or
advanced neoplasia• Colonoscopy relies on GP referral following a +FOBT
(“usual care pathway”)
Patient Experience• Mr HC• 60yr old male• Seen in GI Out patients at RNSH• Letter from GP: “+FOBT”– Dated 9 months before he was seen in general GI
Clinic – Colonoscopy 2 weeks later:
Patient Experience• Mr HC• 60yr old male• Seen in GI Out patients at RNSH• Letter from GP: “+FOBT”– Dated 9 months before he was seen in general GI
Clinic – Colonoscopy 2 weeks later:• Normal
Colonoscopy
Private Patient(or self-insure)
+FOBT
Invited to Participate in
NBCSP
Private Rooms(consultant
controls wait-list)
Out-patient Clinic
Colonoscopy in Public Hospital
Current status
Sees GP(usual care
path)
Flow Chart of Process:
Public Patient
Colonoscopy
Private Patient(or self-insure)
+FOBT
Invited to Participate in
NBCSP
Private Rooms(consultant
controls wait-list)
Out-patient Clinic
Colonoscopy in Public Hospital
Sees GP(usual care
path)
Flow Chart of Process:
Public Patient
Colonoscopy
Private Patient(or self-insure)
+FOBT
Invited to Participate in
NBCSP
Private Rooms(consultant
controls wait-list)
Out-patient Clinic
Colonoscopy in Public Hospital
Sees GP(usual care
path)
Flow Chart of Process:
Public Patient
Cause and effect diagram
Cause and effect diagram
Lack of Clinics!
Cause and effect diagram
Lack of Clinics!
Intervention GP Access and Education:
GP education evening Sept. 2014 Medicare local supported FOBT clinic in their
online newsletter Expedited referral to RNSH using template on
medicare local website
Clinic Triage: Registrar and CNS
• GI Clinic Capacity:– Extended by 1 hour (=25% increased capacity)– Introduction of fortnightly FOBT Clinic
Staff specialist/bulk billed
• Endoscopy Unit Capacity:– All endoscopy lists have slot for 1 FOBT patient
Initial Analysis and Results• Review of colonoscopies performed at RNSH
for the indication of +FOBT
• Before Intervention: 1/7/13 – 15/1/14• After Intervention: 1/7/14 – 15/1/15
Colonoscopy results
Time from Referral to Colonoscopy
50%
25%
75%
Time from Referral to Clinic
Time from Clinic to Colonoscopy
Since January 2015• 106 referrals for FOBT– 94 have had colonoscopy thus far:• 5 cancers• 37 patients with polyps
FOBT Clinic• 60 patients seen in FOBT Clinic– 41 colonoscoped– Timeframes (median; 25% and 75%):• Referral to Consultation: 31 days (20 and 72)• Consultation to colonoscopy: 24 days (21 and 44)• Referral to colonoscopy: 62 days (47 and 109)
Strategies for Sustaining Improvement• 1year funding from Cancer Institute to support CNS.
-Beyond that fund via FOBT Clinic• Quarterly assessment of volume and times to
colonoscopy of FOBT patients (KPI for our unit)
• Strategies in place to deal with increased colonoscopy load– Triage– I extra list/week (extra 250/yr)– Back-fill empty lists
Strategies for Sustaining Improvement• 1year funding from Cancer Institute to support CNS.
-Beyond that fund via bulk-billed FOBT Clinic-Plus increased activity from nurse-run clinic
• Quarterly assessment of volume and times to colonoscopy of FOBT patients (KPI for our unit)
• Strategies in place to deal with increased colonoscopy load (endoscopy unit)– Triage– I extra list/week (extra 250/yr)– Back-fill empty lists
The End (of the beginning)
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