2ww endoscopy is now available in the Community
Make your service choice AFTER completing the form which will guide your decision

Service Selection (complete this section last)	
	Community Endoscopy	Hospital 2ww pathway	
			
Referral Method	eReferral Service	Email	
	Urgency 	2ww	Please email to PCC2wwOxford@nhs.net and request a Read Receipt when sending	
	Specialty	2ww		
	Clinic Type 	2ww Lower GI		
	Clinic Name	Community Endoscopy 2 Week Wait Lower GI service - Witney - InHealth Endoscopy - NV1		
Location	Windrush Health Centre, Witney	Oxford University Hospitals NHS Foundation Trust 	
			I have explained that an appointment may be offered in Oxford or Banbury	
Phone	01993 707786	01865 231 404 (2ww bureau direct dial)	
Office Hours	8am-6pm Mon-Fri	8am - 6pm Mon-Fri	
Postal Address	Inhealth Endoscopy Ltd
West Oxfordshire Direct Access
Community Endoscopy Service	John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU	
Email enquiries (NOT referrals please)	inl.inhealthreferrals@nhs.net	As above	

Patient’s details	Patient’s background and culture	
Surname	Surname	Ethnicity	Ethnic Origin     	
Forename	Given Name 	1st language	Main Language     	
Known as	Calling Name 	Interpreter required? Y    N 	
DOB	Date of Birth 	Age	Age 		
Sex	Gender 	GP details	
Title	Title 	Referring GP 	     	
Address & postcode	Home Full Address (single line) 	GP address	Organisation Name
Organisation Full Address (single line) 	
		GP Tel no	Organisation Telephone Number 	
NHS No	NHS Number 	GP Fax no 	Organisation Fax Number 	
Hospital No	Hospital Number 	Practice Email	Organisation E-mail Address 	
Email	Patient E-mail Address	Referral date	Short date letter merged 	
Phone Numbers	Preferred Number(s)	Can leave message(s)?	Date received	     	
Home tel	Patient Home Telephone 					
Work tel	Patient Work Telephone 					
Mobile tel	Patient Mobile Telephone 					

2 Week Urgent Referral for Suspected Colorectal Cancer (Lower GI)	
	v8.0.4 EMIS Web    November 2017	
2ww referral communication checklist
Essential that you answer all questions in this section	
Please indicate whether you have used the Gastroenterology
 Email Advice Service oxon.gastroenterologyadvice@nhs.net	 No	 Yes - Details ( where appropriate)      	
I have explained to the patient that they may have cancer and I am 
referring them on the 2-Week Wait Suspected Cancer Pathway	 Yes	 No – why not?      	
Is the patient available for an appointment within the next 7 days?	 Yes	NB. Please only submit this referral 
when the answer is Yes	
NB the Fast Track Patient leaflet is currently being adapted for the ERS. Please provide the patient with the ERS paperwork	
IMPORTANT:
Please ensure this patient is available from referral for further hospital appointments and investigations.
Failure to check this may result in wasted appointments.
If the patient cannot attend immediately (e.g. booked travel) please negotiate a delay in referral.
Please indicate any exceptional circumstances here        	
Once cancer has been excluded the patient will be referred back to you, their GP, other than in exceptional 
circumstances where immediate onward referral is deemed clinically necessary by the secondary care clinician	

Step 1 – Community Endoscopy Suitability Criteria	
 can get onto a trolley and be able to roll onto their side (for the endoscopy) and back, unaided
 is under 225Kg (max weight for our trolleys). Last Weight: Single Code Entry: O/E - weight  
 can give Consent
 18 or over	
If you cannot tick all the boxes, refer to the OUH	

Step 2 - ASA Score	Service Advice	
normal healthy patient	1		Suitable for Community Endoscopy	
mild systemic disease	2			
severe systemic disease	3		Referrals to community providers will be triaged and may be directed to secondary care	
severe systemic disease that is a constant threat to life	4		Refer to secondary care	
moribund patient who is not expected to survive	5			

Referral Criteria
(see NICE 2015 https://goo.gl/6nFnsF)	
Your patient is
Age old	Faecal Occult Blood Testing – boxes shaded in pale orange show when to test	
Any age	Unexplained rectal mass		
	Unexplained abdominal mass		
	Unexplained anal mass		
	Unexplained anal ulceration		
< 40	Rectal bleeding AND	Weight loss		
		Iron deficiency anaemia		
		Change in bowel habit	Constipation 		
			Diarrhoea		
		Abdominal pain		
	Iron deficiency anaemia* AND positive FOB		
	Change in bowel habit AND positive FOB		
40 to 49	Unexplained weight loss AND abdominal pain		
	Rectal bleeding AND	Weight loss		
		Iron deficiency anaemia		
		Change in bowel habit	Constipation		
			Diarrhoea		
		Abdominal pain		
	Iron deficiency anaemia* and positive FOB		
	Change in bowel habit AND positive FOB	Constipation		
		Diarrhoea		
50 to 59	Unexplained weight loss AND abdominal pain		
	Unexplained rectal bleeding		
	Abdominal / pelvic pain AND positive FOB		
	Weight loss AND positive FOB		
	Iron deficiency anaemia* AND positive FOB		
	Change in bowel habit AND positive FOB	Constipation		
		Diarrhoea		
60 or over	Unexplained weight loss AND abdominal pain		
	Change in bowel habit	Constipation		
		Diarrhoea		
	Iron deficiency anaemia		
	Unexplained rectal bleeding		
	Abdominal / pelvic pain AND positive FOB		
	Weight loss AND positive FOB		
	Any anaemia AND positive FOB		
*Iron Deficiency Anaemia threshold not defined in NICE 2015	

Fitness for Bowel Prep checklist	
This is required to allow straight to test prior to OP appointment in order to reach an earlier diagnosis

Please ring the triage nurses directly on 01865 226903 if you require further guidance

The referring GP must provide these details to inform fitness for bowel prep as bowel preparation is dangerous in patients at risk of renal failure. The measures defined below must be considered. Failure to do so may lead to an alternative pathway and a delay in the time to diagnosis.

Patients may also be unsuitable for bowel preparation if they have poor mobility, poor cognitive function or other significant comorbidities. Please highlight any concerns in the referral letter section below

For full guidance please refer to http://www.bsg.org.uk/attachments/960_obca_draft_10.pdf
(see page 34 for bowel prep checklist flowchart)

Referrals may be returned without this information to obtain more details

C+Es should be done within the past 3 months (amended May 2017)
Arrange bloods and delay referral until results available
Failure to do so may delay the time to diagnosis
	
Issue	Last recorded data	Manually entered if not autopopulated	
Sodium	Single Code Entry: Plasma sodium level...	     	
Potassium 	Single Code Entry: Plasma potassium level...	     	
Creatinine	Single Code Entry: Serum creatinine...  	     	
eGFR	Single Code Entry: GFR calculated abbreviated MDRD...	     	
Haemoglobin and last ferritin level may be valuable (but no need to delay referral for these results)
Consider other haematinics if ferritin normal or raised in the presence of anaemia	
Last Haemoglobin	Single Code Entry: Haemoglobin estimation	     	
Ferritin	Single Code Entry: Serum ferritin    	     	
Transferrin Saturation Index	Single Code Entry: Transferrin saturation index 	     	
Faecal Occult Blood 	Single Code Entry: Faecal occult blood test  	     	

Oral Iron Supplements	
 NOT taking oral iron	Oral iron should be stopped 1w before an endoscopy	
 taking oral iron		
Safety Checklist
This information will allow patient to move ‘straight to test’	
This patient can stop their antihypertensives for 72 hours		
This patient can stop their diuretics for 24 hours		
This patient does not have unstable heart / renal failure		
In view of associated comorbidity I believe the circumstances need considering by the 
appropriate specialist to decide on the most appropriate pathway for investigation		

Are there any known contraindications to bowel prep?    (please tick boxes as appropriate)
Patients who may not be fit for bowel prep will still be investigated but managed in an alternative way	
Severe Inflammatory Bowel Disease		     	
Toxic megacolon		Single Code Entry: Toxic megacolon  	
Hypersensitivity to bowel cleansing agent		     	
Reduced consciousness level		     	
Ileostomy		Single Code Entry: [V]Has ileostomy  	
Previous history of GI obstruction , perforation or ileus		     	
Dysphagia		Single Code Entry: Dysphagia...  	
There are no known contraindications to bowel prep			

Weight Loss	
	Coded Data	Enter weights manually if not coded	
Referral Weight	Single Code Entry: O/E - weight	     Kg       Date	
	Measured loss	      Kg	
	Patient Reported loss	      Kg	
	Duration	      weeks	
	Coded Data
(duplicates may appear if fewer than 4 measurements exist)	Enter weights manually if not coded	
Previous Weight 1	Single Code Entry: O/E - weight	     Kg       Date	
Previous Weight 2	Single Code Entry: O/E - weight	     Kg       Date	
Previous Weight 3	Single Code Entry: O/E - weight	     Kg       Date	

Management of patients who are receiving anticoagulation

Information required to allow the most patients to move ‘straight to test’ prior to OPA
Failure to supply this information may delay their progress and result in unnecessary appointments	
This patient IS NOT anticoagulated		
This patient IS anticoagulated with	     	
Reason for anticoagulation	     	
Had an INR of	Single Code Entry: International normalised ratio      	On: Single Code Entry: International normalised ratio      	
History of bleeding disorder	 No 	 Yes – details:      	
Taking an Antiplatelet?	 No 	 Yes – details:      	

Please add a referral letter / additional information for clinical use
(please highlight any significant comorbidities)
Failure to provide clinical information may result in delayed treatment	
	Please tick here if you are sending any additional documents. 
The referral narrative should be typed onto this form, not in a separate letter	
	Please tick here if the patient does not meet the 2-week wait criteria but you feel they still warrant
urgent investigation under this pathway, and outline the details below 
This referral will then be triaged by the specialist prior to acceptance	
Please type your clinical referral in the row below	
     	

Additional Patient Information	
Coded data	Manually entered if not autopopulated	
Family cancer history: FH: Neoplasm - *...	Family history any cancer      	
Smoking	Never smoked
Past smoker
Current smoker	

Alcohol Consumption	Alcohol consumption       units per week	
Other Complicating Factors	
vCJD risk	Yes 	 None known 	
Prosthetic heart valve /SBE	Yes 	 No 	
Diabetes	Diet 	Oral 	Insulin 	
Infection risk if known (please specify)	     	

Performance Status Key
to be completed by GP to assist provider with booking an appropriate appointment
Failure to provide this information may lead to a wasted appointment
	
Fully active, able to carry on all pre-disease performance without restriction	0		
Restricted in physically strenuous activity but ambulatory and able to 
carry out light/sedentary work, e.g. house or office work	1		
Ambulatory and capable of self-care, but unable to carry out work activities 
Up and active > 50% of waking hours	2		
Capable of only limited self-care. Confined to bed or chair >50% of waking hours	3		
Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair	4		

Consultations 
Medication
Problems
Allergies