ࡱ> U Xbjbj@@ "ʄi"ʄi@ @ 8#?F*:ddd!# $Z>>>>>>>$C>=%!"!=%=%>9>(((=%>(=%>((;=2%<F>>0#?<D%HD,=D==%=%(=%=%=%=%=%>>A'=%=%=%#?=%=%=%=%D=%=%=%=%=%=%=%=%=%@ X :  WHITTINGTON HEALTH Direct ACCESS Colonoscopy Form (NOT APPLICABLE TO 2WW LOWER GI) Criteria for use To be used for patients requiring GP direct access diagnostic endoscopy only. If specialist input is required please refer to the Gastroenterology or Colorectal service as appropriate. Inclusion criteria Patients > 40 years with unexplained rectal bleeding persisting for at least 6 weeks. Patients > 55 years presenting with rectal bleeding of any duration. Patients > 60 with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding. Patients > 40 with a change in bowel habit for at least 6 weeks. Patients at any age with raised Faecal Calprotectin Patients at any age with unexplained weight loss (usually in combination with gastroscopy) Patients at any age with strong family history of bowel cancer (even if asymptomatic) Exclusion criteria No 2ww patients, these should be referred on existing 2ww pathway. Clinical Management At the colonoscopy, a clinical evaluation will be made and recommendations on further management in primary care or follow up in the Gastroenterology/colorectal surgery clinic. Renal function within the last 12 weeks should be included on the referral form so that bowel preparation can be safely prescribed, and INR (where applicable) Further information Direct access colonoscopy pathway: Referral to Direct Access Colonoscopy Service on ERS. Triage and graded by Clinical lead or any other gastroenterology consultant in their absence. anticoagulation guidance and preferred bowel preparation to be written down (to guide pre-assessment nurses) Endoscopy administration team to scan and save referral in separate folder on I drive under I:\Inpatient Validation\Endoscopy\Gastro STT Colonoscopy Referrals using patient initials and NHS number as file name. Patient booked in by endoscopy administration team accordingly to the triaged criteria in any available lower GI endoscopy slot 2 points unless otherwise indicated on referral. Admin team book into endoscopy pre-assessment clinic. Patient pre-assessed and any issues to be raised to clinical lead primarily, or any other gastroenterology consultant in their absence. Paper prescription issued by clinical lead (or any other gastroenterology consultant / non-medical prescriber in their absence) for required bowel preparation to send to patient/collection from department. After the procedure, follow up booked or discharge back to GP as per endoscopy report, such as CMORS (virtual histology clinic)/Gastro clinics/Red top referral to colorectal surgical clinic/Discharge to GP. Contacts Dr Clive OnnieEndoscopy STT service Leadvia switchboardSonia Kumari Service Manager for Endoscopy and Gastroenterology07796 932434 sonia.kumari1@nhs.netAlex CampbellGeneral Manager for Medical Specialtiesalexander.campbell1@nhs.netTarjau Greene-DavidDeputy Service Manager for Endoscopy and Gastroenterology07469 645433 tarjau.greene-david@nhs.netEndoscopy admin team0207 288 3822 whh-tr.endoscopy@nhs.netCristina AguiarEndoscopy Nurse Manager020 7288 3812 Cristina.aguiar@nhs.net WHITTINGTON HEALTH Direct ACCESS Colonoscopy Form PLEASE NOTE: THIS FORM SHOULD NOT BE USED FOR SUSPECTED COLORECTAL CANCER REFERRALDATE: Email: whh-tr.endoscopy@nhs.net Please attach referral to eRS appointment within 24 hours. Fax is no longer supported due to patient safety and confidentiality risks. PATIENT DETAILS: SURNAME: FIRST NAME: TITLE:  FORMTEXT      GENDER: FORMTEXT       DOB:  FORMTEXT       NHSNO: FORMTEXT       ETHNICITY:  FORMTEXT       LANGUAGE:  FORMTEXT       FORMCHECKBOX  INTERPRETER REQUIRED (specify language):  FORMTEXT        FORMCHECKBOX  TRANSPORT REQUIREDPATIENT ADDRESS:DAYTIME CONTACT NO:  FORMTEXT      HOME:  FORMTEXT       MOBILE:  FORMTEXT       EMAIL:  FORMTEXT      GP DETAILS:GP NAME:PRACTICE NAME:PRACTICE ADDRESS:MAIN CONTACT NO: EMAIL:REASON FOR REFERRAL. PLEASE GIVE AS MUCH CLINICAL INFORMATION (DO NOT USE THIS FORM FOR 2WW LOWER GI INDICATIONS): SUITABILITY FOR STRAGHT TO TEST ONLY THOSE PATIENTS WITH PERFORMANCE SCORE OF 0-2 WILL BE CONSIDERED FOR COLONOSCOPY. Please tick performance score. 0 Fully active, able to carry on all performance without restriction FORMCHECKBOX  1 Restricted in physically strenuous activity, but ambulatory and able to carry out light work FORMCHECKBOX  2 Patient is mobile with a stick, ambulatory and capable of all self-care FORMCHECKBOX  3 Mobile with a Zimmer frame, unable to carry out any work activities FORMCHECKBOX  4 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours FORMCHECKBOX  5 Patient confined to bed or chairSUITABILITY FOR STRAIGHT TO TEST FORMCHECKBOX  Patient has dementia FORMCHECKBOX  Patient has learning disability FORMCHECKBOX  Patient is on anticoagulant or antiplatelet agents (except aspirin). 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