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L.S. JONES, R.W. NICHOLSON and D.A. EVANS
Department of Surgery, Blackburn Royal Infirmary, Blackburn U.K.
Background and objective: Colorectal services have traditionally been arranged for the convenience of hospitals rather than patients. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this a one-stop colorectal clinic was set up. Patients and Methods: Weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays for a period of 6 months. Patients with rectal bleeding, altered bowel habit, anorectal symptoms and those requesting screening advice were seen by a consultant or specialist registrar. Patients were asked to fill in a questionnaire at the end of their clinic attendance. Results: 197 patients were seen in 17 clinics; 134 underwent proctoscopy, 72 had a rigid sigmoidoscopy and 85 had a flexible sigmoidoscopy carried out. Twenty-four patients subsequently had a barium enema and 3 were listed for colonoscopy. The main diagnosis was haemorrhoids (n=104); 14 colorectal neoplasms were discovered (5 cancers and 9 polyps). During the study period the number of patients waiting for lower gastrointestinal endoscopy fell from 119 to 63; 2 months after ending the pilot scheme, the number had risen to 108. Conclusion: The clinic was found to have significantly improved patient care. The majority of patients were satisfied with an evening clinic. Flexible sigmoidoscopy without sedation was well tolerated and the ability to perform this at initial assessment had a marked effect on the number of patients awaiting lower gastrointestinal endoscopy.
Keywords: Colorectal neoplasms, one-stop clinic, rectal bleeding sigmoidoscopy
J.R.Coll.Surg.Edinb., 46, April 2001, 96-97
Colorectal services have traditionally been arranged for the convenience of a hospital and its staff rather than for patients. Consultations and procedures are carried out in different places and at different times. This model is not ideal, particularly for minor interventions and diagnostic procedures. In order to address this issue we set up a ‘one-stop’colorectal clinic.
The aims of this pilot clinic were:
MATERIALS AND METHODS
The clinic was located in the endoscopy/day case unit. Two consulting rooms, one endoscopy suite and two separate waiting rooms, one with lavatory facilities, were available. Each clinic was staffed by two doctors (one consultant and one specialist registrar), five nurses (one ‘E’grade, two ‘D’grades, two ‘A’grades) and a clerical assistant. Two consultant surgeons were involved, each with a declared colorectal interest; they attended the clinic on alternate weeks. Three flexible sigmoidoscopes, four reusable rigid sigmoidoscopes and disposable proctoscopes were used. Blood tests were performed as indicated. Requests for radiological investigation generated by this clinic were given a degree of preference by the radiology department. The same was true for histopathology requests.
Financially, the pilot scheme was made possible by shifting resources from general surgical daytime clinics, with an additional contribution from waiting list moneys.
The weekly clinics ran from 6.00 to 9.30 p.m. on Wednesdays. General practitioner referral letters were examined and patients in the following categories were considered suitable for the clinic; those with rectal bleeding, with altered bowel habit, with anorectal symptoms, and with a family history of bowel cancer or polyps. Patients requiring ambulance transport were excluded. An appointment letter and clinic information sheet were sent to each patient.
A history was taken and clinical examination carried out in consulting rooms equipped with facilities for rigid sigmoidoscopy, proctoscopy and rubber band ligation. Flexible sigmoidoscopy was carried out as indicated rather than according to a strict policy. If a flexible sigmoidoscopy was felt to be necessary then consent was obtained and a phosphate enema (Pharmax Ltd) administered. Patients waited in a separate room with toilet facilities until the enema had worked. No sedation was given.
The impact of the clinic on waiting list numbers for lower gastro-intestinal endoscopy was studied. Patients were asked to fill in a short questionnaire at the end of their visit and were invited to give comments.
Two hundred and sixteen patients were sent an appointment for the clinic, 19 of whom failed to attend. 197 patients were seen in 17 clinics (12 patients per clinic). Ninety-three of the patients (47%) were male and 104(53%) were female. Patients waited a mean of 34 days (range 9-142 days) between the date of general practitioner referral and the date of being seen. Long waiting times were usually due to patients cancelling their first appointment. The main reasons for referral are shown in Table 1, the main diagnoses in Table 2, and procedures in Table 3.
Table 1: Main reason for referral
| Main reasons for referral | Number of cases (%) |
|---|---|
| Rectal bleeding | 125 (63) |
| Anorectal symptoms | 39 (20) |
| Altered bowel habit | 20 (10) |
| Request for screening | 1 (<1) |
|
Other |
12 (6) |
Table 2: Main diagnoses
| Main diagnosis | Number of cases (%) |
|---|---|
| Haemorrhoids | 104 (52.8) |
| Anal fissure | 19 (9.6) |
| Colonic polyps | 9 (4.6) |
| Colorectal cancer | 5 (2.5) |
| Inflammatory bowel disease | 13 (6.6) |
| Irritable bowel syndrome | 7 (3.6) |
| Diverticular disease | 4 (2.0) |
|
Other |
36 (18.3) |
Table 3: Procedures performed
| Procedure | Number (%) |
|---|---|
| Proctoscopy | 134 (68) |
| Banding of haemorrhoids | 81 (41) |
| Flexible sigmoidoscopy | 85 (43) |
| Rigid sigmoidoscopy | 72 (37) |
|
Polypectomy |
5 (3) |
In the 85 patients that underwent flexible sigmoidoscopy, 72 (85%) were found to have had an adequate bowel preparation and in 59 (70%) it was possible to reach the proximal sigmoid colon or beyond.
At the inception of the clinic 119 patients were on the waiting list for lower gastrointestinal endoscopy. At the end of the 6-month period this had fallen to 63. Two months after ending the pilot scheme the number had risen to 108 (Figure 1).
Figure 1: Number of cases on waiting list for lower gastrointestinal endoscopy
Results from the patient questionnaire indicated that the majority of patients were satisfied with an evening clinic. Only 26 (13%) would have preferred a daytime appointment, the majority of whom were women with young children. Patients found the hospital quieter, parking was easier and those who normally worked in the daytime found the evening appointment more convenient. There were no adverse comments relating to the performance of flexible sigmoidoscopy without sedation.
The main effect of this pilot clinic was to allow flexible sigmoidoscopy at the time of first consultation. This speeded up the diagnostic process and saved the patient from having to make an additional trip to hospital. Flexible sigmoidoscopy without full bowel preparation and without sedation was clinically feasible. An evening clinic time proved to be popular and had a number of advantages.
There is currently a great deal of interest in the speeding up of colorectal cancer diagnosis and one-stop clinics are seen as an aid to this. In this respect it is important to note that only five new cancers were diagnosed from the clinic. The vast majority of patients had benign and clinically trivial disease; nevertheless it is this group, through early diagnosis, treatment and reassurance, who stand to gain most from such clinics.
ACKNOWLEDGEMENTS
We would like to thank Sister Jean Robinson and all the nursing staff who have contributed towards the development and successful running of this clinic. The article was presented in poster form at the annual meeting of the Association of Coloproctology of Great Britain and Ireland, Jersey 1998.
Copyright date: 31st January 2001
Correspondence: D.A. Evans, Consultant Surgeon, Department of Surgery Blackburn Royal Infirmary, Bolton Road, Blackburn BB2 3LR, U.K.
Email: bhrvhct@btinternet.com
©2001 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb.