Information for healthcare services – Colonoscopy Clinical Care Standard

What the standard says

When a patient is referred for consideration of colonoscopy, the referring clinician provides sufficient information for the receiving clinician to assess the appropriateness, risk and urgency of consultation. The receiving clinician or service allocates the patient an appointment according to their clinical needs.

What this means for healthcare services

Healthcare services supporting referrals

Use consistent processes to ensure that referrals are accurate and comprehensive to enable assessment and prioritisation. Use an appropriate template, preferably electronic. See the Commission’s Colonoscopy Referral Information for further information.

Healthcare services receiving, allocating or prioritising referrals 

Ensure that clear referral guidelines are available for referring clinicians, identifying the type and format of clinical information required. Ensure that processes support the provision of services according to the patient’s clinical priority. Using agreed, standardised templates, preferably electronic, can assist the communication of important information between referring clinicians and colonoscopy services. 

For open-access services, processes and procedures should ensure adequate consideration of the patient’s comorbidities, current medications, risks and suitability for the procedure and: 

• Include a process to assess the suitability of the patient for a direct-access procedure
• Include a process to obtain the patient’s relevant information, including the dates and findings of previous colonoscopies
• Provide the opportunity for contact between the patient and a suitably trained clinician (including a registered nurse or nurse practitioner) before the day of the procedure to enable the patient to ask questions about the procedure, including about potential risks, benefits, and bowel preparation; this may be via telehealth when appropriate.

What the standard says

A patient is offered timely colonoscopy when appropriate for the investigation of signs or symptoms of bowel disease, surveillance or screening, as consistent with national evidence-based guidelines. Decisions are made in the context of the patient’s ability to tolerate the bowel preparation and colonoscopy, and their likelihood of benefit. If colonoscopy is not appropriate, the receiving clinician advises the patient and their referring clinician of alternative recommended management.

What this means for healthcare services

Ensure that policies and processes support the timely and appropriate provision of colonoscopy. This includes: 

• Supporting and promoting clinicians’ use of national evidence-based guidelines, including Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer and Clinical practice guidelines for surveillance colonoscopy
• Supporting and encouraging clinician participation in quality improvement and peer‑review processes. 

For healthcare services that receive referrals, ensure that policies and procedures for triage and scheduling of colonoscopy appointments for bowel cancer-related indications reflect guideline recommendations from the Cancer Council Australia in regard to timeliness of follow‑up or investigation. Consider state and territory-based colonoscopy categorisation criteria, such as NSW Agency for Clinical Innovation’s NSW colonoscopy categorisation and Victoria Department of Health’s Colonoscopy categorisation guidelines, as relevant to the setting. 

What the standard says

Before starting bowel preparation, a patient receives comprehensive patient‑appropriate information about bowel preparation, the colonoscopy, and sedation or anaesthesia. The patient has an opportunity to discuss the reason for the colonoscopy, the risks, benefits, financial costs and alternative options before deciding to proceed. Their understanding is assessed, and the information provided and their consent to sedation, colonoscopy and therapeutic intervention is documented.

What this means for healthcare services

Ensure that clear, written information is available to patients for all aspects of the colonoscopy for which the health service organisation is responsible. This may include information about bowel preparation, the colonoscopy and associated sedation or anaesthesia. 

When consent is being obtained, ensure protocols and procedures enable patients to receive adequate information to inform their decision, are supported to ask questions, and provide consent before the start of bowel preparation. Ensure interpreter services are accessible, and their use is supported. Ensure policies and procedures support the principles and practices of informed consent and appropriate documentation.

What the standard says

A patient booked for colonoscopy receives a bowel preparation product and dosing regimen individualised to their needs, comorbidities, regular medicines and previous response to bowel preparation. The importance of good bowel preparation for a quality colonoscopy is discussed with the patient. They are provided with consumer-appropriate instructions on how to use the bowel preparation product and their understanding is confirmed. 

What this means for healthcare services

Ensure that policies and procedures support best practice for bowel preparation. Support patients by enabling access to information about bowel preparation. Healthcare services with responsibility for providing bowel preparation and advice should ensure processes to: 

• Provide clear, written patient information about the bowel preparation procedure
• Provide access to interpreter services or translated materials
• Provide a telephone number for enquiries patients may have during bowel preparation
• Enable clinical staff to periodically review and approve patient information.

Where relevant to the facility, ensure policies support providing extra assistance to patients who are unlikely to manage bowel preparation independently, including overnight admission if needed. 

What the standard says

Before colonoscopy, a patient is assessed by an appropriately trained clinician to identify any increased risk, including cardiovascular, respiratory or airway compromise. The use of sedation is planned accordingly. The risks and benefits of sedation are discussed with the patient. Sedation is administered and the patient is monitored throughout the colonoscopy and recovery period in accordance with Australian and New Zealand College of Anaesthetists guidelines.

What this means for healthcare services

Sedation and anaesthesia should be provided in accordance with current ANZCA recommendations such as the Guideline on procedural sedation (PG09), Guideline for the perioperative care of patients selected for day stay procedures (PG15) and Position statement on informed consent for anaesthesia or sedation (PS26).

Ensure that local policies and procedures are in place, and services adequately resourced, to implement the ANZCA guidelines. Policies should ensure that pre‑sedation assessment is carried out by appropriately trained clinicians to identify patients who are not suitable for intravenous sedation in the absence of an anaesthetist, and to plan for sedation accordingly. Policies should include arrangements for providing colonoscopy without sedation where the managing colonoscopist has assessed this as clinically appropriate for the patient and it is the patient’s preference.

Ensure that clinicians who administer sedation or anaesthesia for colonoscopy are credentialed by the health service organisation and are operating within their defined scope of clinical practice. Ensure that clinicians maintain their skills by participating in ongoing professional development and review of performance. Ensure sedationists achieve the Safe Sedation Competencies as described by ANZCA. Implement and ensure compliance with policies and procedures for the safe supervision of trainees, where relevant to the facility. 

What the standard says

A patient’s colonoscopy is performed by a credentialed clinician working within their scope of clinical practice, who meets the requirements of an accepted certification and recertification process. Sedation or anaesthesia, and clinical support are provided by credentialed clinicians working within their scope of clinical practice. 

What this means for healthcare services

Identify credentials that are required for clinicians to perform colonoscopy or provide sedation or anaesthesia for patients undergoing colonoscopy, and ensure credentialing processes are adequate, as set out in Credentialing health practitioners and defining the scope of clinical practice: A guide for managers and practitioners. 

For clinicians performing colonoscopy, identify accepted certification and recertification processes according to their clinical speciality and professional body and use this when credentialing clinicians and defining their scope of clinical practice. For trainee colonoscopists working towards certification, implement and ensure compliance with policies and procedures for the safe supervision of trainees. Ensure that non-anaesthetist clinicians who provide sedation fulfil the training and competencies outlined in the Safe Sedation Competencies and are targeting an appropriate level of sedation (minimal to moderate sedation), as described in ANZCA’s Guideline on procedural sedation (PG09). Support participation by clinicians in peer-review activities. 

What the standard says

When a patient is undergoing colonoscopy their entire colon – including the caecum – is examined carefully and systematically. The adequacy of bowel preparation, clinical findings, biopsies, polyps removed, therapeutic interventions and details of any adverse events are documented. All polyps removed are submitted for histological examination. 

What this means for healthcare services

Establish procedures to collect and periodically monitor the quality of colonoscopies at the service level, including caecal intubation, adenoma detection rate, sessile serrated lesion detection rate and adequacy of bowel preparation. Review and share organisation and clinician-level data findings with clinicians as part of quality monitoring and clinical quality improvement activities (such as clinical review meetings). Ensure that the number of patients booked on each list enables the colonoscopist to undertake a careful and systematic examination of each patient’s colon. Review list sizes periodically as part of procedures to monitor the quality of colonoscopies at the healthcare service. Ensure a process is in place to act promptly and effectively on any results suggesting substandard quality.

Provide systems that require and support colonoscopists to maintain accurate records of the colonoscopy. This includes the adequacy of bowel preparation, biopsies taken, polyps removed and retrieved, all diagnostic and therapeutic interventions, details of any adverse events and procedure duration. Ensure complications and adverse events of colonoscopy are reported and monitored in the organisation’s incident management system and other relevant systems and investigated appropriately.

Ensure that the standard of equipment provided for colonoscopy supports safe, high‑quality colonoscopy, including for visualisation and photodocumentation. Ensure that organisational policies and procedures support the assessment of technology and equipment used for colonoscopy to identify the benefits and consequences of use, and appropriate clinical governance.

What the standard says

Following recovery and before discharge, the patient is advised verbally and in writing about the preliminary outcomes of the colonoscopy, the nature of any therapeutic interventions or adverse events, when to resume regular activities and medicines, and arrangements for medical follow‑up. The patient is safely discharged into the care of a responsible adult, in accordance with Australian and New Zealand College of Anaesthetists guidelines.

What this means for healthcare services

Ensure that policies and procedures for monitoring, supervising and discharging patients align with current recommendations for post‑operative care following sedation or anaesthesia (for example, ANZCA’s Guideline for the perioperative care of patients selected for day stay procedures [PG15]).

Ensure that procedures are in place for discharging patients into the care of a responsible adult. Exceptions to post‑sedation supervision by a responsible adult and transport to their discharge destination (excluding driving or public transport) should be based on the clinical judgement of the clinician managing sedation. Exceptions should take into account the depth of sedation and be in accordance with ANZCA guidelines.

Provide written instructions about early post‑procedure care and resumption of normal activities, including medicines. Ensure that there is a response plan for patients in the event of problems arising post‑discharge. Provide patients with discharge information, including specific health service contact details after hours. 

Pre‑admission procedures should identify patients who genuinely cannot identify a responsible adult to accompany them home and stay with them overnight and allow for suitable arrangements to be made, according to their risk. Policies should allow for extended recovery periods and overnight admission, if needed, for patients who have comorbidities and cannot be cared for adequately at home in the immediate period post‑discharge or who do not meet discharge criteria (as appropriate to the type of facility). 

What the standard says

The colonoscopist communicates the reason for the colonoscopy, its findings, any histology results and recommendations for follow‑up in writing to the general practitioner, any other relevant clinician and the patient. This information is recorded in the facility records and other electronic shared record management systems to enable accurate follow‑up by other clinicians. Recommendations for surveillance colonoscopy, if required, align with national evidence-based guidelines. If more immediate treatment or follow‑up is needed, the colonoscopist makes appropriate arrangements.

What this means for healthcare services

Ensure that policies and procedures clearly delineate responsibilities for managing patient recall and follow‑up for the colonoscopist, the health service and the GP. Ensure that policies and procedures for information management and communication reflect these arrangements. To ensure complete reporting of colonoscopy, policies should: 

• Include arrangements for the reporting of all histology results if any tissue was removed, regardless of the histological findings
• Ensure surveillance intervals are updated based on histology results
• Ensure histology results, updated surveillance intervals and other recommendations are uploaded to the facility records and other shared record systems such as the My Health Record
• Ensure the colonoscopy report, histology outcomes and surveillance intervals are provided to referring clinicians (GPs), other relevant clinicians and the patient
• Support reporting to the National Cancer Screening Register for patients referred through participation in the National Screening Program.

Ensure systems are in place for the prompt communication and management of histologically confirmed colorectal cancer or high‑risk lesions. Support and promote clinicians’ use of national evidence-based guidelines, such as the Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer and Clinical practice guidelines for surveillance colonoscopy, when making recommendations for future surveillance and follow‑up.