Colorectal Suspected Cancer TWW Straight to Test on ICE

The ICE TWW referral for colonoscopy is intended to apply to those patients who comply with NICE TWW guidelines. For the system to work best it is essential that the referring GP checks that the patient knows why they are being referred and that they are available to attend within the next two weeks.

Colorectal cancer is one of the commonest cancers that GPs diagnose and using current guidance, a patient who complies with the TWW guidlines has a 3% risk of having cancer. For these patients who do not comply with the guidelines, their risk of cancer is therefore quite low.  Prime Endoscopy and Emerson’s Green provide a prompt effective investigation service, and qFIT is now available for those low risk but not no risk patients.

TWW Straight to Test on ICE

Colonoscopy:  At referral the GP will be making a judgement on the appropriates of the test for their patient. Colonoscopies are not without risk, and so no patient should be referred, by either eReferral or ICE, if they are not fit for the test, if there is a contraindication or of they are unable to take the bowel prep at home.

A patient information leaflet explaining the preparation and procedure is available by clicking the little book icon. See Appendix 1. screen shot 3

The clinician will be asked to confirm the following details:

*It is worth making sure you gather this information before starting the form to avoid the frustration of having to come out of ICE to find it.

  • Contraindications for colonoscopy
  • Capacity to consent to the procedure
  • patient fitness – can the patient turn unaided 
  • co-morbidities - If diabetic or hypertensive a recent eGFR will be required
  • infection – the presence of current infection is a contraindication 
  • current medication - iron tablets should be stopped.
  • Anticoagulation 
  • Patient contact phone number
  • Patient availability in the next two weeks

The clinician will also be asked to agree to be the prescriber of the bowel preparation, which will be dispensed by the Hospital.

As sedation and analgesia will be used it is advisable that the patient has someone at home the evening of the procedure

As a rule of thumb, if a patient is over 80yrs, or if there is any doubt as to the appropriateness of colonoscopy, the patient should be sent to clinic rather than direct to test.

Flexible Sigmoidoscopy is the investigation of choice for those patients rectal bleeding.

CT Colonoscopy CTC is less invasive, the bowel prep less aggressive, so is a more appropriate investigation for frail or elderly patients. However, note that this investigation is not sensitive to picking up lesions at the ano-rectal junction and so please ensure that a rectal PR examination has been carried out. If polyps are identified another referral will be needed to arrange their removal.

Clinical referral

  • If there is any doubt as to the appropriateness of colonoscopy, the patient should be sent to clinic rather than direct to test.
  • Patients with a rectal mass should be sent to clinic rather than for an endoscopy
  • If cancer has been excluded by in the past year, but symptoms persist a clinic referral is the best course of action so that other pathologies can be explored.
  • GPs are asked not to double book patients, for example, do not send to clinic and also refer for endoscopy as this wastes appointments.
  • Polyps identified which are >6m will be reviewed in 3yrs, but to note that lesions <2cm have <40% risk of becoming cancerous.

In summary

Direct referral on ICE for TWW Colonscopies & CTC have been available in North Bristol for the past 3yrs and has proven to shorten the patient pathway from 28days to 11 days. It is acceptable to GPs and patients. It enables clinic availability for more complex and frail patients.

The roll out of this service to UBHT will ensure a uniform service across the whole BNSSG region.

If an eReferral could have been made via ICE this will be highlighted to the referring clinician, eventually only clinic appointments will be made by eReferral.

NBT Screen Shots for Navigating on ICE

Screen Shots for Navigating on ICE

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Algorithm CRC TWW on ICE

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