The effectiveness of new criteria for colorectal fast track clinics

Abstract

INTRODUCTION: Fast Track Colorectal Clinics are becoming a requirement to meet the government's 10-day rule for patients with suspected cancers to be seen by a specialist. However, such clinics soon tend to get overwhelmed by huge numbers of referrals, many of them inappropriate. The Association of Coloproctology of Great Britain and Ireland has published criteria for appropriate referral. We evaluated the sensitivity of these criteria and attempted to recommend appropriate changes. METHODS: Data of 50 consecutive colorectal cancers from our DGH since January 2000 has been collected in relation to demographics, presenting signs and symptoms, haemoglobin levels as well as treatment. The new Criteria were then applied strictly to these cases and we evaluated whether these patients would have been eligible for fast track referral, if these criteria had been in force since January 2000. RESULTS: Forty-one (82%) of 50 patients would have been eligible for referral as follows: 11 (22%) rectal bleeding with diarrhoea; 8(16%) persistent diarrhoea without bleeding (>60 years), 12 (24%) bleeding without anal symptoms (>60 years), 0 (0%) palpable right sided abdominal mass, 7 (14%) palpable rectal mass, 16 (32%) iron deficiency anaemia (<11 g/dl in men & <10 g/dl in women), 10 (20%) patients qualifying on more than one criterion. However, 9 (18%) patients had presenting features that would have excluded them from a fast track referral as follows: 4 (8%) only abdominal pain + weight loss (48, 54, 72, 75 years old), 2 (4%) change in bowel habit + no rectal bleeding (54, 57 years old), 1 (2%) palpable mass at a site other than the right side of the abdomen. CONCLUSIONS: We feel that this study, although small, highlights the dangers of having very rigid criteria for such clinics. The new criteria though high in specificity have low sensitivity for safety. We recommend some modifications to the criteria as follows: rectal bleeding without anal symptoms >50 years instead of 60 years; patients with a palpable mass anywhere on the abdomen; and the adddition of a new criterion of abdominal pain with weight loss. These modifications would significantly increase the sensitivity from 82% to 94%.

Fast Track Open Partial Nephrectomy: Reduced Postoperative Length of Stay with a Goal-Directed Pathway Does Not Compromise Outcome

“…Previous studies of other types of major surgery have shown that a combined effort comprising intensive preoperative information, effective postoperative pain relief and enforced mobilization, and early enteral nutrition can accelerate postoperative recovery and decrease hospital stay [11, 13]. …”

“…Investigators have recently illustrated that in elderly high-risk patients undergoing colonic resection, mean hospital stay could be reduced to 2-3 days [11]. In another group of high risk patients undergoing open aortic surgery, mean hospital length of stay was reduced from a mean of 9 days to 5 days [14–16].…”

“…In another group of high risk patients undergoing open aortic surgery, mean hospital length of stay was reduced from a mean of 9 days to 5 days [14–16]. In a study by Harinath et al, a decrease in length of stay was observed from 5 to 4 days for ileal pouch-anal anastomosis [11]. The concept of fast track has also been applied to infants and children [17].…”

“…Factors limiting early discharge are usually pain, stress-induced major organ dysfunction (i.e., ileus, atelectasis), tradition, fatigue, pain, nausea, and morbidity [8, 9]. In other abdominal procedures, including colon resection, lung transplant, and laparoscopic nephrectomy, the introduction of a program comprised of optimized pain relief using nonsteroidal anti-inflammatories for analgesia enforced oral nutrition and mobilization, and revision of traditional care principles has reduced hospital stay from 5–8 days to 220 133 days in some studies [10, 11]. The concept of fast-track (FT) surgery has recently attracted more interest, but has not yet been applied in patients undergoing partial nephrectomy.…”

Criteria for Referring Patients With Outpatient Gastroenterological Disease for Specialist Consultation: A Review of the Literature

“…Several authors suggested that combinations of two or more symptoms increases the level of urgency [12, 17, 22, 33, 36] Lawrenson et al [22] pointed out that the absolute risk of colorectal cancer for patients presenting with a combination of two symptoms (anaemia and rectal bleeding, anaemia and changes in bowel habit, or rectal bleeding and changes in bowel habit) is about twice as high as those with any single symptom. In a prospective study of 8529 patients referred to a surgical clinic over a 12-year period, Thompson et al [36] evaluated change in bowel habit, rectal bleeding, abdominal pain and perianal symptoms along with age as predictors of colorectal cancer.…”