Authors (including presenting author) :
Lee HY
Affiliation :
Department of Surgery, Princess Margaret Hospital
Introduction :
Lower GI symptoms are a common cause of new case referral to the colorectal clinic and significant portion of these is the non-urgent cases which are made up by patients referred for PR bleeding. Occasionally, we do encounter patients confirmed to have colorectal cancer, who were initially described to have PR bleeding or altered bowel habit in the referral letter. In view of long waiting time for non-urgent cases in HA, it may inevitably increase the chance of delay in cancer detection and related treatment. Therefore, shortening waiting time of new case referral should be significantly focused.
Besides, because of increasing public awareness and early detection of colorectal cancer, the number of colorectal cancer patients being treated in earlier stage and 5-year survivors are predicted to increase. Subsequently, the demand of life-long surveillance becomes a great burden in SOPC in HA and it prolongs the first colorectal consultation waiting time in public hospitals which may potentially lead to missing serious illness diagnosis. Apart from this, the traditional clinician-led survivorship clinic is mainly focus on surveillance investigations and disease recurrence but usually not include addressing the side effects and psychological needs raised from patient after treatment completion. Therefore, nurse-led survivorship clinic may enhance the overall life quality of colorectal survivors by addressing psychological well-being, providing support and information to reduce treatment related side effect, and health promotion to minimize the risks of recurrence as well as share the burden of colorectal surgeons and SOPC.
Apart from colorectal cancer, bowel functional disorder is also a great problem in Hong Kong. According to survey, constipation was one of the most common gastrointestinal complaints and one in nine people in Hong Kong reported experiencing constipation in the month before interview. Moreover, great demand of bowel function service for colorectal cancer survivors is attributed to increasing new case number of colorectal cancer and anal-preserving surgery as the main trend of treatment. Bowel dysfunction may affect patient's life quality, physical and psycho-social health and it is essential to provide comprehensive care on bowel function in Hong Kong.
Objectives :
Newly development of colorectal nurse clinic is aim to provide a comprehensive service to assess, support, manage, and educate patients and families with colorectal disease or bowel function problems according to pre-approved protocol and international guidelines. Using an integrated model, it targets (1) early detection of colorectal cancer cases and avoid delay in treatment for non-urgent cases; (2) reduction of pressure on Colorectal SOPC and shorten the waiting time for new case consultation; (3) expansion of colorectal nursing service on pelvic floor disorder and bowel dysfunction for increasing trend of new colorectal cancer case.
Methodology :
IMSN colorectal nurse clinic is divided to 3 main pathways: (1) Colorectal triage clinic; (2) Colorectal cancer survivorship clinic; (3) Colorectal bowel function clinic. The clinic is run by an experienced colorectal specialty nurse who has gone through proper training in terms of history taking, abdominal and per rectal examination, colorectal disease and bowel function management.
New case referral with lower GI symptoms will be screened by CR specialists for patient truly belongs to non urgent category and those patients will be referred to attend the colorectal triage clinic. All patients attending the clinic go through a comprehensive history taking, abdominal and rectal examination. Dietary advice and lifestyle modification is provided to patients who are suffering from hemorrhoids. Surgeon also assess the patient in clinic by performing proctoscope. Colonoscopy would be arranged and its priority is based on the symptoms and pre- approved protocol. Doctor clinic follow up is arranged for pathology report. Thus, waiting time of new case referral and doctor consultation time will be shortened. Those patients having suspicious symptoms will be given an earlier colonoscopy appointment to achieve early cancer detection.
All colorectal cancer survivors will be arranged to attend the survivorship clinic after 3 months of curative operation along with CR follow up for explaining surveillance investigation and follow up plan, management on acute post-treatment side effect and bowel dysfunction, health promotion, and psychological support to aid smooth transition from cancer sufferer to survivorship. For the stable survivors undergone curative operation beyond 5 years who are eligible for selection criteria will be referred by CR specialists and transited to the survivorship clinic for life-long yearly follow up. Comprehensive physical examination and history taking is performed with arrangement of surveillance colonoscopy / CEA checking if indicated in survivorship clinic. Patient will be referred back to CR specialists if any suspicious symptoms of cancer recurrence according to pre-approval protocol.
The new case referral or old case in colorectal clinic with bowel dysfunction is referred to bowel function clinic if patients agree and are eligible for inclusion criteria. Patient is first assessed by surgeon for formulating the treatment plan, followed by the nurse clinic. All patients will go through comprehensive history taking, bowel function assessment, abdominal and per rectal examination with various nursing interventions for improving bowel function given. The progress will be reviewed by CR specialists periodically in case conference.
Result & Outcome :
In one-year service of colorectal nurse clinic:
Mean waiting time of non-urgent new case referral with lower GI symptoms in traditional out-patient clinic is 53 weeks while it is greatly shortened in colorectal triage clinic to 12 weeks. Total 322 patients were arranged for colonoscopy and 61 of them were completed. Detection rate of colorectal cancer and colonic polyp is 6.6% and 37.7% respectively.
For colorectal cancer survivorship clinic, total 168 survivors after 3 months of curative operation were recruited for health promotion to minimize disease recurrence, management on bowel dysfunction after treatment and psychological support. On the other hands, total 322 stable survivors undergone curative operation beyond 5 years were transited from colorectal doctor clinic to survivorship nurse clinic for further survivorship care. Hence, the workload and burden of colorectal doctor clinic can be shared and colorectal surgeons can more focus and concentrate on cancer diagnosis and related treatment.
In bowel function clinic, total 218 patients having bowel function problem were recruited with 100 patients exited. 60% of exited patients reported that the bowel function was improved in terms of scoring system and bowel symptoms after following nursing interventions provided in nurse clinic. Moreover, second-line interventions including anorectal manometry, biofeedback, pudendal nerve motor latency test and transanal irrigation had been already implemented to bowel function clinic for complicated case.
Patient satisfaction survey was carried out for 6 months and mean score was 4.9/5.
