Lower GI 2 Week Wait (2ww)/ Direct to Test (DTT) Exploring ... · • 1.1.1.1 Advise the patient...

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Lower GI 2 Week Wait (2ww)/ Direct to Test (DTT) Exploring National differences Maria Pettman Colorectal Nurse Consultant

Transcript of Lower GI 2 Week Wait (2ww)/ Direct to Test (DTT) Exploring ... · • 1.1.1.1 Advise the patient...

Page 1: Lower GI 2 Week Wait (2ww)/ Direct to Test (DTT) Exploring ... · • 1.1.1.1 Advise the patient that more than one investigation may be necessary to confirm or exclude a diagnosis

LowerGI2WeekWait(2ww)/DirecttoTest(DTT)Exploring

Nationaldifferences

MariaPettmanColorectalNurseConsultant

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• WhatamIheretotalkabout?• Whyisitimportant?• WhatdidIdo?

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Historyof2ww

• ReferralGuidelinesforSuspectedCancer

• NICEguidelines[CG27]Publisheddate:June2005

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NiceLGI2wwreferralguidelines(2015)

• Colorectal cancer• 1.3.1Referpeopleusingasuspectedcancerpathwayreferral (foranappointmentwithin2weeks)forcolorectalcancerif:• theyareaged40andoverwithunexplained weightlossandabdominalpainor• theyareaged50andoverwithunexplainedrectalbleedingor• theyareaged60andoverwith:• iron-deficiencyanaemia or• changesintheirbowelhabit,or• testsshowoccultblood intheirfaeces (seerecommendation1.3.4forwhoshouldbeofferedatestforoccultblood in

faeces).[new2015]• 1.3.2Considerasuspectedcancerpathwayreferral(foranappointmentwithin2weeks)forcolorectalcancerinpeoplewith

arectalorabdominalmass.[new2015]• 1.3.3Considerasuspectedcancerpathwayreferral(foranappointmentwithin2weeks)forcolorectalcancerinadultsaged

under50withrectalbleedingand anyofthefollowingunexplainedsymptomsorfindings:• abdominalpain• changeinbowelhabit• weightloss• iron-deficiencyanaemia.[new2015]• 1.3.4Offertestingforoccultbloodinfaeces toassessforcolorectalcancerinadultswithoutrectalbleedingwho:• areaged50andoverwithunexplained:• abdominalpainor• weightloss,or• areagedunder60with:• changesintheirbowelhabitor• iron-deficiencyanaemia,or• areaged60andoverandhaveanaemia evenintheabsenceofirondeficiency.[new2015]

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NICEguidance(part1ofpathway)• 1.1Investigation,diagnosisandstaging• Therecommendationsinsection1.1refertopeoplewhoseconditionisbeingmanagedin

secondarycare.Forrecommendationsforurgentreferralfromprimarycare forpatientswithsuspectedcolorectal cancer seereferral forsuspectedcancer (NICEguidelineCG27).

• 1.1.1Diagnosticinvestigations• 1.1.1.1Advisethepatientthatmorethanoneinvestigationmaybenecessarytoconfirmorexclude

adiagnosisofcolorectal cancer. [2011]• 1.1.1.2Offercolonoscopytopatientswithoutmajorcomorbidity,toconfirmadiagnosisof

colorectal cancer. Ifalesionsuspiciousofcancer isdetected,performabiopsytoobtainhistologicalproofofdiagnosis,unlessitiscontraindicated(forexample,patientswithabloodclottingdisorder).[2011]

• 1.1.1.3Offerflexible sigmoidoscopythenbariumenemaforpatientswithmajorcomorbidity.Ifalesionsuspiciousofcancer isdetectedperformabiopsyunlessitiscontraindicated.[2011]

• 1.1.1.4Considercomputedtomographic(CT)colonography asanalternative tocolonoscopyorflexible sigmoidoscopythenbariumenema,ifthelocal radiologyservicecandemonstratecompetencyinthistechnique.Ifalesionsuspiciousofcancer isdetectedonCTcolonography,offeracolonoscopywithbiopsytoconfirmthediagnosis,unlessitiscontraindicated.[2011]

• 1.1.1.5Offerpatientswhohavehadanincomplete colonoscopy:• repeatcolonoscopyor• CTcolonography,ifthelocalradiologyservicecandemonstratecompetency inthistechniqueor• bariumenema.[2011]

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Whatguidelinesarewegiven?

• NICE(UpdatedguidelinesApril2016)

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Questionnaire

• Whoreceivesreferrals?• Whovetsreferrals?• Dovetting'sgetdonedaily?• HowdoesDirecttotest(DTT)getdecided?• DoesDTTincludef/sandcolonoscopy• Whotakesresponsibilityforprescribingbowelprep?• PercentageofpatientswhogoDTT• Whodecideswhichconsultantthepatientgoesunder?• Whoreviewsresults?• Whathappenstobenigndisorders?

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Regions• Midlands1• South-West1• Midlands2• EastAnglia• Oxfordshire• North- West• South-West2• London1• Midlands3• Midlands4

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Whoreceivesreferrals?Midlands1 2wwAdminoffice

South-West 1 Endoscopy unit

Midlands2 CNSteam

EastAnglia Teamof6nonclinicalstafffollowingspecificguidelines.

Oxfordshire CNSteam

North- West CNSteam

South-West 2

onlinealgorithmforGP'stofollowandbookcolonoscopy orCTCdirectlyalsofacilitytobookpatientintoclinic.

London 1 CNSteam

Midlands3 Surgeons

Midlands4 CNS

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Whovetsreferrals?Midlands1 CNP's

South-West 1 Surgeons

Midlands2 CNSteam

EastAnglia Teamof6nonclinicalstafffollowingspecificguidelines.

Oxfordshire CNSteam

North- West CNSteam

South-West 2 Notneeded seepreviousanswer.

London 1 CNSteam

Midlands3 Surgeons

Midlands4 CNS

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Dovetting’sgetdonedaily?Midlands1 oncedailyCNPandconsultant

South-West 1 Donedaily.Rota

Midlands2 Yes

EastAnglia Daily

Oxfordshire twicedaily

North- West twicedaily(bywhoever isinoffice)

South-West 2 Notneeded

London 1 daily

Midlands3 ?

Midlands4 Daily

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HowdoesDirecttotest(DTT)getdecided?Midlands1 CNPandconsultantdecide

South-West 1 Surgeonsdecide

Midlands2 ClinicaljudgementofCNSteam

EastAnglia ConsultantGastroenterologistandNurseEndoscopist

Oxfordshire Byeveryone

North- West over70'sclinic,under70'sgetanassessmentphone callbyCNS

South-West 2 Notneeded

London 1 NoDTT

Midlands3 NoDTT

Midlands4 NODTT

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DoesDTTincludef/sandcolonoscopyMidlands1 Both

South-West 1 Both

Midlands2 Both

EastAnglia Both

Oxfordshire Both

North- West colonoscopy, f/sandCTC

South-West 2 Notneeded

London 1 NA

Midlands3 NA

Midlands4 NA

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Whotakesresponsibilityforprescribingbowelprep?

Midlands1 CNP's

South-West 1 Surgeons

Midlands2 CNSteam

EastAnglia asabove

Oxfordshire CNSteam

North- West CNSteam– atpre-assessment

South-West 2 GP

London 1 CNSteam

Midlands3 Surgeons

Midlands4 CNS

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PercentageofpatientswhogoDTT?Midlands1 50-35%

South-West 1 40%

Midlands2 60% ?

EastAnglia 80%

Oxfordshire 100%?

North- West 25%

South-West 2 ?

London 1 NA

Midlands3 NA

Midlands4 NA

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Whodecideswhichconsultantthepatientgoesunder?

Midlands1 Rota

South-West 1 Whoeverdoesprocedure

Midlands2 Rota

EastAnglia Rota

Oxfordshire MDTlead

North- West CNSteam

South-West 2 Thealgorithmstoppedatcolonoscopy.Unsurewhatfollows

London 1 NA

Midlands3 NA

Midlands4 NA

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Whoreviewsresults?Midlands1 CNP's

South-West 1 whoeverdoesprocedure

Midlands2 CNSteam

EastAnglia whoeverrefersfortest

Oxfordshire CNSteam

North- West CNSteam

South-West 2 Thealgorithmstoppedatcolonoscopy.Unsurewhatfollows

London 1 Medical Team

Midlands3 Surgeons

Midlands4 CNSteam

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Whathappenstobenigndisorders?Midlands1 BacktoGP

South-West 1 ?

Midlands2 BacktoGP

EastAnglia BacktoGP

Oxfordshire BacktoGPbutmaykeepIBDpts

North- West Patientssortedoutonthispathway.

South-West 2 Thealgorithmstoppedatcolonoscopy.Unsurewhatfollows

London 1 DischargeallnoncancerptsbacktoGP

Midlands3 DischargeallnoncancerpatientsbacktoGP

Midlands4DischargeallnoncancerpatientsbacktoGPapartfromIBDpatientswhoarereferreddirectlytogastro

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Whyisthisbecomingmoreimportant?

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ThenewNICEreferralguidelines, published inJunelastyear,loweredthethresholdofriskforGPstorefersomeone forinvestigativetestingiftheycomeforwardwithconcerning

symptoms.Theguidelines alsosupport GPsaccessinginvestigativetestsdirectlythemselves.CancerResearchUKandMacmillan

CancerSupporthaveworkedwithNICEtosupportGPswithtoolsandresourcestohelpthemputthesenewguidelines intopractice.

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PointstoconsiderwithDTT

• Complicationrate• Anti-coagulants• Consent• Bowelprep• Prescribingbowelprep• Ethnicminorities• Colonoscopycanbepainful!

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IdealpathwayforDTTneedstoinclude

• Dedicatedteamwhocanassessfromreferralwhetherpt isappropriateforDTTorOutpatientclinic

• Preassessment,facetofaceortelephone• Thatsameteamshouldalsoberesponsibleforprescribingbowelprep.

Or• Computerised

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Thankyou


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