Lessons learned from Bowel Screening Pilot

Clinical Director’s perspective

Mike Hulme-Moir

Clinical Director• Background colorectal surgery• Broad role encompassing:

- Public relations/Front person/Communication

(Team, Patients, Management, MOH, GPs,

Cancer, clinicians, Media/Public, Lab)

- Quality overarching principle- Clinical work endoscopy,

histopathology, - Problem solving (team based)- Expect the unexpected

Build a good team

• Too much for one person to do sans support

• Management, nursing, endoscopy, surgical, quality, GP, pathology/Lab

GPs

• Valuable/Vital/Essential component of our program• Need total buy-in from them• Education/Liaison

Education takes time……lots of time, mainly after hours

• Need to be available preferably on the phone to talk over issues

Endoscopy Governance/Quality• Currently no permanent national structure to ensure and

oversee quality within a national bowel screening program• NEQuip has provided excellent service to date but its future

structure/funding is uncertain• NOW is the time to sort out a national endoscopy

governance structure with the following aims:

To set acceptable standards for competence in endoscopic procedures

To quality assure endoscopy units

To quality assure endoscopy training

To quality assure endoscopy services• Governance body should service all endoscopy not just

screening

Histopathology• There are thousands of results.

- 16185 in first 3 years• Consistency is vital esp

surveillance recommendations• Less is best but one is too few!!!• Nurse led histology is an answer• Fellow consultants like to own

their own histology• Formatted letters with

personalised service as needed

Cancer management

• Histopathology• Referral processes• MDM• Workforce issues

Initial hump and then ongoing referrals

Referral processes• Robust ..don’t lose pts• Standardised • Efficient ie get bloods and

radiology done up front (2 week agreement with radiology)

Colon ct, blds, info pack,mdm referral

Rectal ct, mri, blds, info pack, mdm referral

• Provide information to patients

MDM

• Need one!!!• Quality standard• Many are easy• Many are not!

Rectal cancer

Malignant polyps

Advanced disease

Bowel Screening findings (2012-2014)

• 5818 public colonoscopies in 5716 patients, 516 private colonoscopies• 271 cancers in 261 patients

231 cancers/224 patients treated in public

40 cancers/37 patients treated in private

148 males, 113 females• 10 public non-adenocarcinoma cancers/lesions (scc,carcinoid etc)

3 ot (r-hemi x2 and eua bx), 2 chemo/rad, 1 chemo• 27 pub pts required OT for benign disease (polyps DD etc)

- 15 r hemicolectomy- 3 ant resection +/- ileostomy- 1 transverse colectomy- 1 subtotal colectomy- 7 TEMs or trans anal procedures

• 1 Private non adenoca cancers/lesions- 1 chemo/rad

• 4 priv pts required OT for benign disease

- 3 r hemicolecotomy- 1 high ant resection

Total BSP cancersn = 271

R colon

8130%

L colon 11643%

Rec-tum 73

27%

cancer site

0

5

10

15

20

25

30

35

40

45

50

44

23.7 22.7

8.1

1.4

Stage data for public cancers

stage

perc

enta

ge

BSP vs Symptomatic cancer workload(2014 n= 359 of 450 P1 referrals, not including 15 non adenocarcinomas)

68

11

30

62117

71

Total CR cancers for 2014 (359)

BSP 19% other DHB 3% private 8% GP/specialists 17% gastro 33% acute 20%

BSP cancer impact• Surgical work load

- New Pt clinic time average one hour per new cancer- (includes FSA, nurse specialist, stoma and ERAS)

- Operating time on average one half day list per cancer

- 11/181 pts leaked (6%) - 9 needed extra half day lists to fix and rejoin

- Follow-up clinics several over 5 years

- Stoma closure average of 15 per year (7.5 lists)

- 2/10 FTE for BSP CD

• Endoscopy work load

- Extra lists for complicated pts or polyps mostly under ga

- Surveillance

- Cancer followup scope at 3 years/5yearly thereafter

BSP cancer impact• Laboratory work load (doesn’t include polyp work)

- 3 hours per cancer (on average) • 1 hr technician time• 1.75 hrs pathologist time• .25 hrs clerical time

- Lab tests for inpatients

• Radiology

- Every patient needs a staging CT

- All rectal cancers need an MRI as well

- Almost all major complications needed CTs, also one ivc filter for PE

• Ancillary services

- CNS see each patient

- Ethnic support services, cancer tracking

- Stoma therapists (46 stomas, 2 permanent and 44 temporary)

• Bed space 6 day median bed stay for elective colorectal cancer surgery

Colonoscopic/Surgical complications

• 68 readmits from colonoscopy

6 laparotomies for bleeding(4), perforation (2)• 11 leaks

9 reoperation and 2 non operative

Workload data• WDHB population 575,000• Assume one surgeon 2 x 4 hour lists

per week for 46 weeks per year (92 lists per year) plus 1 x 4 hour clinic, 1 x 4 hour endo list

• We need 0.5 FTE surgeon per year to cope with the new bsp work load but in addition there is extra work closing stomas (7.5 lists per year (2 per list). Real FTE is probably closer to .6

• Acute surgery per year as a result of BSP ie 3 leaks, 2 laparotomies for bleeding/perf per year

• Approx .1 FTE surgery for each 100,000 population screened