Reducing waiting time for colonoscopy after positive FOBT

Senior clinicians within the hospital identified the issue of long waiting times for colonoscopy for patients who have had a positive faecal occult blood test (FOBT) as one of the top priorities due to both high risk and high volume: 

• Almost 5000 colonoscopies are performed in the health service each year.
• Gastroenterology and surgical clinical staff raised concerns about delays to colonoscopy services following the introduction of the National Bowel Cancer Screening Program.  
• Root cause analysis of a patient death identified the long waiting time between positive FOBT and colonoscopy as an important contributing factor.
• Feedback from colorectal cancer patients invited by Cancer Services to talk about their experiences raised the problem of delays between referral and treatment.
• A group medical student project on waiting lists for surveillance colonoscopy, presented at a surgical and medical meeting, found variation in waiting times.

A clinical nurse consultant (project manager), two gastroenterologists, and two surgeons worked together to determine what the target waiting time should be, and found the following:

a. The National Bowel Cancer Screening Program monitoring reports include the national median time between a positive screening test and diagnostic assessment, which was 54 days. No relevant clinical quality registries or audits were identified.

b. Two recommendations were identified for waiting time between a positive faecal occult blood test (FOBT) and colonoscopy: 

• The National Bowel Cancer Screening Program performance framework recommends a maximum of 30 days. 
• Cancer Council Australia guidelines state that colonoscopy should be performed as promptly as possible after a positive FOBT to minimise psychological harm, although there is no evidence that prognosis is worsened within 120 days if cancer is present. 

The project team decided to aim for a maximum of 30 days between referral and colonoscopy.

The team decided to regularly monitor waiting times for colonoscopy, and compare it with the national median, the benchmark waiting period.

The project manager reviewed records for all patients referred for colonoscopy due to a positive faecal occult blood test over a one-month period. The median waiting time was 82 days, and the range was 28 – 435 days. The project manager presented the findings to medical, nursing and administrative staff at a department meeting. 

The long median waiting time showed substantial variation from the chosen benchmark of a maximum of 30 days, and the wide range showed large variation within the service. The team decided the risk of harm to patients was high, and warranted immediate action.

The project team identified the key relevant staff, including the endoscopists, cancer services, facility managers, bookings administrators, and information technology experts. The team met with these groups to discuss the causes of the long waiting times, as well as challenges and potential improvements. The discussions identified two major reasons for delays:

• Waiting for appointments at the gastroenterology outpatient clinic for screening for suitability for colonoscopy, which could be done by phone.
• Referrals to individual clinicians for colonoscopy rather than for the next available list vacancy in the service.

Surveillance colonoscopies accounted for a large proportion of procedures, and after review of records, the team found that many patients underwent surveillance more frequently than guidelines recommend.

The team also noticed a high proportion of patients were having both gastroscopy and colonoscopy. They accessed gastroscopy data for their local hospital network area using the interactive Australian Atlas of Healthcare Variation which showed a markedly higher rate than the national average. They also reviewed the relative rates of upper and lower gastrointestinal cancer in Australia (Figure). A review of the outcomes of gastroscopies performed in the hospital on patients without indications showed no serious pathology was found over one year.

Redesigning the referral and booking system was agreed as the best way to reduce delays. The health service executive allocated a position to set up a direct access colonoscopy model.  

A process for rapid access with phone screening was developed, with suitable patients proceeding to colonoscopy and bypassing outpatient clinics. The allocation to colonoscopy lists was based on patient factors, colonoscopy wait list size and time. 

A HealthPathway for colorectal and positive FOBT referrals was developed, including a standardised referral form and a central referral point for all patients. Education sessions were delivered to referring GPs on FOBT screening and the new referral system.

The team also put in place referral criteria for gastroscopy to reduce unnecessary procedures and to free up theatre time for colonoscopies for people with positive FOBTs. They also put in place systems to alert clinicians to the recommended follow up intervals for surveillance colonoscopy.

A review of the six-month pilot of the rapid access colonoscopy model showed that the median waiting time was reduced by 38 days (46%) compared with the previous data, and the range narrowed to 11-188 days. The service is continuing to monitor waiting time each quarter to check whether the improvements are sustained, and reports the results to the hospital board.

The service is continuing the quality improvement cycle by trialling further system changes, with the aim of achieving a maximum 30-day waiting time. The changes and corresponding data are reported back to clinicians and the board regularly.