AUDIT SECTION 9: COLONOSCOPY SURVEILLANCE Units were asked about the number of patients on the colonoscopy surveillance waiting list. This means patients who need to have regular screening for a variety of reasons such as a family history of polyps (not including bowel cancer screening). Not all units were able to provide this information (those with 0 in the table below). Table 1 Units were asked to state what percentage of these patients received their examination within 6 weeks of the target date. Most units were unable to provide this information. Of those that did, the figures ranged from 10 100%, with the majority between 85 100%. Units were also asked what guidelines they followed for colonoscopy surveillance. Fourteen of 16 responses specified the BSG (British Society of Gastroenterologists) guidelines. One stated the ACPGBI (Association of Coloproctology of Great Britain and Ireland) Guidelines. All described their practice.
AUDIT SECTION 10: BARRETT S OESOPHAGUS Common policy for Barrett s Table 2 Units were asked about the factors they took into consideration in their policy. Then responses were recorded for each factor as follows: Table 3 Table 4 Page 2
Table 5 Table 6 Table 7 Table 8 Page 3
AUDIT SECTION 11: COMMENTS Things That Are Working Well Unit Things That Are Working Well Comments BCH Mater RVH Antrim Excellent patient satisfaction survey results; Good staff retention; Good working relationships with Medicine, Surgery and Theatre; Compliance with the Hine report on decontamination; Only dedicated endoscopy unit; Diversity of procedures; Staff development; Direct links with A+E. Medical endoscopists (i.e. Two Consultant Gastroenterologists and one Staff Grade) provide cross cover for endoscopy lists during annual and study/professional leave to minimise cancellation of endoscopy lists. This has helped to keep the waiting times for endoscopy down. The Unit functions well. There are good relationships between medical and surgical teams, and between consultants and nurses. There is good flexibility within the Unit e.g. slotting in urgent cases. Computerised system in place for referral of urgent endoscopy procedures for medical inpatients. Assessed daily by medical staff, risk stratified then allocated reserve slots accordingly. Patient GRS satisfaction survey completed recently (questionnaires sent to 216 patients, 54% return over 90% generally satisfied with service). 84% of patients consented outside the procedure room. Causeway Mid Ulster Whiteabbey No Comment Recorded No Comment Recorded GRS Pain tool audit underway which includes caecal intubation rates (Dr C Rodgers, M Kyle) Bowel preparation audit underway comparing efficacy of 3 different bowel preparations (Dr Nick Kelly) Audit recently completed regarding patient flow which included length of patient wait for outpatient appointment and length of wait for colonoscopy (conducted by Dr Nenda Reddy, SHO now in Mid Ulster Hospital). Page 4
Ards Nurse endoscopy managing own patients impact on waiting list reduction Downe Lagan Valley Ulster Craigavon & South Tyrone Nurse Endoscopist has reduced waiting lists, patients appreciative of service, positive feedback from GPs Nurse Endoscopists have greatly reduced waiting times. Open access for both upper and lower is working well. Urgent patients are being seen within 2 weeks. Patients are impressed that they do not have long to wait on arrival and the efficiency of their stay. Sending a letter home with the patient as well as a copy to GP is good practice so if the patient has to call out a doctor all the information is available. Nurse Endoscopist service managing own patients has impact on waiting lists Efficient patient flow within DPU high throughput Daisy Hill Altnagelvin Erne Tyrone Enthusiastic staff. Medical & Surgical Staff Grades now JAG accredited in colonoscopy. Theatres installed Unisoft GI reporting tool for same day reports and as a tool for Audit. Back fill of lists when endoscopists are on leave. Decontamination unit staffed by HSDU. Scope storage cupboards/facilitates prompt start to a.m. lists. Endoscribe system works well and all our consultants use it. Nursing staff Key Bottlenecks / Constraints Unit Key Bottlenecks / Constraints Comments BCH Limited 10 bed recovery (2 slots inpatient beds; 8 trolleys); Limited capacity for emergency endoscopy on routine lists; Limited toilet facilities in Unit; X ray screening equipment needs replaced; No recurrent replacement for ageing equipment; Increasing demand from Cancer Centre for therapeutic endoscopy (no extra funding); No lead for GRS audit; Increasing demand from DHSSPS targets re waiting times; Lack of full staff to complement all sessions available; increased therapeutic procedures impact on staffing; lack of endoscopists. Page 5
Mater RVH Antrim Causeway Mid Ulster Main constraint is the lack of equipment to run additional endoscopy sessions in the second endoscopy room in DPU. Decontamination equipment will also need to be upgraded to increase capacity. Management of cancellations the process of contacting patients needs to be improved (for example often patients claim to have cancelled rather than DNA but there is no record within the department). The Administrative support team has produced an action plan to improve key processes. Ability to provide urgent inpatient endoscopy remains problematic as there are insufficient urgent lists. There is an issue about the appropriateness of some referrals therefore filtering / triage processes need to be developed (e.g. by Nurse Endoscopist or Staff Grade). The highest level of inappropriate referrals is from GP direct access (this service needs to be reviewed and is not working efficiently). Urgent and red flag patients are not seen quickly enough to comply with the Cancer Access standards. The quality of information needs to be improved. The geography of the unit poses a problem as there is no dedicated space for consenting patients (space was given to neuroradiology which is now vacated again and needs to be reallocated back to Endoscopy). Some patients are sent for CT Colonogram as an alternative to colonoscopy due to long waiting times (when colonoscopy would be the preferred option). There is likely to be unmet demand. 1. AER malfunction 2. Age of scopes. 3. Back tracking of patients through the unit due to layout and admission and discharge carried out in same area. 4. No private consulting rooms for consent, breaking bad news etc. 5. Waiting lists trying to ensure quality with quantity. 6. No current out of hours endoscopy service provision. No Comment Recorded Restricted recovery space as also used for other day cases/day surgery. Capacity available in unit but funded medical sessions not. Inadequate medical records cover Page 6
Whiteabbey Waiting list pressures have spare, but unfunded, capacity. Staffing levels inadequate staffing and situation exacerbated by sick/maternity leave. Unable, at times, to release staff for training. Unable to afford an element of supernummery status to endoscopy nurses in initial stages of training therefore prevents ongoing, continual training of new staff. 2 units in one area day surgery/day procedure. Easier to manage as 2 separate areas. Geographical layout admission and discharge area as one, patients back track through the department, limited private consultation areas, spare endoscopy room capacity but not always recovery capacity due to surgical procedures. Ards Downe Lagan Valley Ulster Craigavon & South Tyrone Daisy Hill Pooled waiting list PAS only allows patient to be added to cons name, list capacity, poor IT back up lack of available sessions lack of equipment e.g. scopes AERs need staff to reprocess None Nurse endoscopists could have more lists if there were more resources. Sterilisers are poor and constantly break down. There are problems with having enough clerical staff. Pooled waiting lists PAS only allows patient to be added to cons name, list capacity not enough sessions, poor it backup, lack of scopes /AERs/ staff for processing Funding for 5.5 sessions weekly Accommodation constraints. Too few scopes some equipment old in STH Too few endoscopes and some >15 years old. Reduces list efficiency because of gaps for disinfection. Old scopes probably result in more incomplete procedures and greater patient discomfort and risk. Page 7
Altnagelvin Erne Tyrone Inpatients cause major delays on lists. This is due to time it takes bringing patients to and from wards. Lack of recovery spaces can also delay lists. In our unit there are 6 spaces set aside for paediatrics that canʹt accommodate adults. Several other specialties use the area and also restrict recovery of endoscopy patients. This will be even more difficult to manage when the 3rd room is operational. Stand alone endoscopy unit would be of benefit both for through put of patients and management of staff. This would enhance quality of care. GPs sometimes send patients in for procedures who are on anti coagulant therapy which poses a problem should the patient require biopsies. Consultants not on site need to travel from sister hospital 34 miles away. Continued overruns due to late starts. Page 8
PROCESS EVALUATION How was the data collected? Trusts collected the audit data and sent it to NICaN in excel format. A copy of the proforma can be seen in Appendix A of this document. NICaN arranged for the data to be input by a third party, using excel. The Regional Clinical Lead for Endoscopy analysed the data and the reports were completed. What did Trusts say about the process? Comments were sought from Trusts on the audit proforma. Responses showed that Trusts found it difficult to collect some of the data. The main reason for this is that the data is not routinely collected, so there are not good systems in place to record it. At the beginning of the audit, it was agreed that communication about the audit would be through a single identified contact in each Trusts. This person would make sure the information was passed on to everyone in that Trust who needed to know about it. This method was not effective in all Trusts. In two Trusts, this meant that the data was submitted after the closing date because units didn t get enough advance notice about the audit. What has happened as a result of these comments? As a result, a document with the names of the main contacts for endoscopy services in Northern Ireland was produced. This is available on the NICaN website www.nican.ni.nhs.uk. An email list of all endoscopists in Northern Ireland was also created. Future communication about the Modernising Endoscopy Services Project will be to a much larger group and will not depend on Trust internal communication systems, except where this has been specifically requested by a Trust. Page 9