The Direct Access Colonoscopy Clinic (DACC) is an innovative nurse-led clinic that fast tracks people with a positive faecal occult blood test (FOBT) who meet set clinical criteria through to colonoscopy, thus avoiding the wait time to see a gastroenterologist.
Aim
The project received a two-year funding grant from the Cancer Institute NSW to reduce waiting times for positive FOBT patients accessing colonoscopy services. The overall aim was to decrease the incidence of colorectal cancer in the Far West Local Health District (LHD).
Benefits
- Provide a better understanding of local barriers for referral pathways, triage processes, and waiting lists
- Reduce waiting times for positive FOBT patients accessing colonoscopy services in Broken Hill
- Provide a service that is efficient, equitable and based on current best practice guidelines
- Reduce morbidity and mortality through cancer prevention, by patients receiving the right care at the right time by the right person
Background
Bowel Cancer accounts for 12.2% of all cancer deaths in NSW.1 In the Far West LHD , 150 people will be diagnosed with bowel cancer over the next five years.2 In 2007, FOBTs were introduced into Australia, resulting in an increase in referrals to gastroenterology services nationally. The national benchmark for a positive FOBT is a colonoscopy within 120 days of referral, and triaged as Category 1.
Through data collection, analysis and patient journey mapping, it was determined that in Broken Hill, a person with a positive FOBT often waited up to 12 months to see a visiting gastroenterologist, followed by a further wait for a colonoscopy. In addition, gastroenterology appointments were allocated based on date of receipt of referral (within that particular triage category). For example, a person with no risk factors in Category 1 would be seen before a person with risk factors or symptomatology in Category 1 based on the date of their referral. Positive FOBT patients were also categorised incorrectly on the colonoscopy waiting list (allocated Category 2 instead of Category 1).
Implementation
The project received two-years funding from the Cancer Institute NSW in 2016. Following redesign methodology, DACC was the proposed model of care to address access issues to colonoscopy. DACC is an innovative nurse-led clinic that fast-tracks people with a positive FOBT (who meet set clinical criteria) through to colonoscopy, thus avoiding the wait-time to see a gastroenterologist.
Patients referred to the DACC nurse are triaged, assessed, provided with education and information, and included on the theatre list for a colonoscopy, thus reducing the overall wait time to colonoscopy. Providing more detailed education, counselling and support ensures that the person feels more comfortable to proceed with the colonoscopy, and results in greater compliance.
DACC also assists patients who have poor bowel preparation, preventing unnecessary use of a gastroenterologist appointment. To ensure patients are seen based on need and risk factors, and not referral date, severity categories have been successfully implemented within triage Category 1 (Cat 1 A, Cat 1 B, and Cat 1 C).
Processes for escalating care have also been streamlined, with the DACC nurse able to fast-track people with worsening symptoms for review, preventing further delays in accessing appropriate care. The DACC follows up people who have been provided a recommendation for admission but have not yet been placed on the theatre list for a colonoscopy.
Various resources, forms, templates, referral pathways, and information technology solutions have been developed as part of this project including, but not limited to, patient triage and assessment forms, patient information leaflets, bowel preparation instructions, etc. Through addressing system and clinical gaps, the DACC program ensures that patients with a positive FOBT receive the right care at the right time, which will in the longer term, prevent cancer and reduce subsequent morbidity and mortality.
Status
Sustained – The project has been implemented and is sustained in standard business.
Dates
- Start date – September 2016
- End date – June 2018
Implementation sites
- Broken Hill Health Service, Far West LHD
- General practices including Royal Flying Doctor Service (referral agents)
Partnerships
- Cancer Institute NSW
- University Department of Rural Health
- Western NSW Primary Health Network
- Hunter New England LHD
- Visiting Gastroenterologists (Adelaide)
- Clinical Redesign Unit
Results
The DACC project started in September 2016, with the clinic go-live-date September 2017. A formal evaluation was undertaken by the University Department of Rural Health.
Prior to the project, 582 patients were waiting to see a gastroenterologist. 20 months later, in June 2018, the waiting list was reduced to 104 patients.
Prior to DACC, positive FOBT patients waited up to 454 days for a Gastroenterologist appointment. Now 86% of patients are seen within 30 days.
Prior to DACC, no patients attended colonoscopy within the National Health and Medical Research Council's recommended timeframe.3 By June 2018, 74% of DACC patients attended within the current 120 day recommendation and 72% of DACC patients had pre-cancerous lesions removed. Previous delays to colonoscopy could have had dire consequences for these patients.
Additional benefits of DACC
- Video-conference appointments for patients living in outlying centres
- Flexible appointments – not relying on visiting specialist times
- Follow-up and support given for reluctant or fearful patients
- Cross referrals to other services e.g. dietitian, health and fitness
- Positive patient evaluations, including letter of gratitude
- Local contact, intermediary for general practitioners and visiting gastroenterologists
- Reduced waiting times for other patients requiring a gastroenterology outpatient appointment due to freeing up of appointments through the use of the DACC for FOBT patients
Awards
DACC won the 2018 Far West LHD Innovations Award - Phoenix (Large Project) Category. Along with the 2018 Far West LHD ACI Innovation Award. The project was judged on its ability to challenge traditional practices and adopting a service redesign approach.
Lessons learnt
- Referral pathways for general practitioners need to be simple and compliance often requires reinforcement.
- Engagement with key stakeholders (particularly visiting gastroenterologists) along the DACC patient journey has been fundamental to the project’s success.
- A systems approach using redesign methodology is important for sustainability.
- The project is transferable to many rural settings, with Central Coast LHD adopting the Far West LHD DACC model for their own local context. Orange Health Service (Western NSW LHD ) has also used some of the DACC resources.
- Due to the success of the Far West LHD DACC service, a second 18 month funding grant has been provided by the Cancer Institute NSW to expand the project to include follow-up and surveillance of positive FOBT patients.
- Through demonstrated successes and improved patient health outcomes, the aim is that the DACC service becomes an ongoing model of service delivery in Broken Hill.
- The project has been presented and well received at the 2018 Cancer Institute NSW Innovation Conference.
References
- Cancer Institute NSW. Cancer statistics NSW. Eveleigh NSW: Cancer Institute NSW; 2018. Accessed 18 December 2018.
- Cancer Institute NSW. Bowel Cancer Statistics. Eveleigh NSW: Cancer Institute NSW; 2018. Accessed 18 December 2018.
- The National Health and Medical Research Council. Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. NHMRC: 2017.
Contact
Kellie Hammond
DACC Nurse Consultant / Project Officer
Phone: 08 8080 1247 Mobile: 0428 582 504
Kellie.Hammond@health.nsw.gov.au
