2 Week Urgent Referral for Suspected Upper GI and Hepato-Pancreato-Biliary Cancers	
v8.0.4 EMIS Web    November 2017	

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 Upper GI		
	Clinic Name	Community Endoscopy 2 Week Wait Upper 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		
Sex	Gender	Age	Age 	GP details	
Title	Title	Referring GP	     	
Pt 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	
Phone Numbers	Preferred Number(s)	Can leave messages?	Date of ref	Short date letter merged	
Home tel 	Patient Home Telephone			Date ref received	     	
Work tel	Patient Work Telephone 					
Mobile tel	Patient Mobile Telephone 					

2ww referral communication checklist
It is essential that you answer all questions in this section	
Please indicate whether you have used the Gastroenterology 
Email Advice Service  oxon.gastroenterologyadvice@nhs.net	 Yes	 No 	
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	

Useful information (see NICE 2015 http://bit.ly/NICE-Cancer-Upper-GI)	
Consider non–urgent direct access upper gastrointestinal endoscopy to assess for 
oesophageal cancer in people with haematemesis. [new 2015]

Consider non-urgent direct access upper gastrointestinal endoscopy to assess for oesophageal cancer in people aged 55 or over with:
•	treatment-resistant dyspepsia or
•	upper abdominal pain with low Haemoglobin levels or
•	raised platelet count with any of the following:
o	nausea
o	vomiting
o	weight loss
o	reflux
o	dyspepsia
o	upper abdominal pain, or
•	nausea or vomiting with any of the following:
o	weight loss
o	reflux
o	dyspepsia
o	upper abdominal pain [new 2015]

NB Unexplained Iron Deficiency Anaemia should be referred using the 2ww Colorectal pathway	

2ww Endoscopy
Community or Hospital	
Your patient is now Age old 	
Oesophageal and 
Gastric	Upper abdominal mass consistent with stomach cancer		Refer for Endoscopy to either OUH or Community clinic depending on suitability described below	
	Dysphagia (any age)			
	≥ 55 with weight loss 
and any one of	Upper abdominal pain			
		Reflux			
		Dyspepsia			

OR

2ww suspected upper GI cancer (not endoscopy)
Hospital services only	
Pancreatic	Aged 40 or over with jaundice		If you are concerned that this patient needs to be seen immediately please contact the on-call service for an immediate clinic review / USS
Hepatology secretary at Gastro.OUH@nhs.net	
	N.B. Fast track issues may include:
•	Fever or rigors 
•	Poor oral intake and is at risk of dehydration
•	Bilirubin > 100
•	Please discuss with on-call if in doubt about the referral path		
	≥ 60 with weight loss
and any one of	Diarrhoea		Consider 
urgent direct access CT 
scan
 (to be performed within 2 weeks). Discuss with on-call radiology where necessary	
		Back pain			
		Abdominal pain			
		Nausea			
		Vomiting			
		Constipation			
		New-onset diabetes			
Gallbladder	Upper abdominal mass consistent with enlarged gallbladder			
Liver	Upper abdominal mass consistent with enlarged liver			
Please tick here if you have sent or are sending an
urgent ultrasound / CT scan request		Mark the Urgency in ICE as “2ww”	

Not referring for endoscopy? Skip to the next page

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			

Oral Iron Supplements	
 NOT taking oral iron	Oral iron should be stopped 1w before an endoscopy	
 taking oral iron		

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 into the row below	
     	

Test Results	
	Coded results	Manually entered if not autopopulated	
Last Hb	Single Code Entry: Haemoglobin estimation	Date & Result:      	
Last WBC	Single Code Entry: Total white cell count  	Date & Result:      	
Last Platelets	Single Code Entry: Platelet count  	Date & Result:      	
Last Sodium	Single Code Entry: Serum sodium...   	Date & Result:      	
Last Potassium	Single Code Entry: Serum potassium...	Date & Result:      	
Last Creatinine	Single Code Entry: Serum creatinine...  	Date & Result:      	
Last eGFR	Single Code Entry: GFR calculated abbreviated MDRD...  	Date & Result:      	
Last CRP	Single Code Entry: Plasma C reactive protein	Date & Result:      	
Last Bilirubin	Single Code Entry: Serum bilirubin level	Date & Result:      	
Last ALT	Single Code Entry: Liver enzymes	Date & Result:      	
Last ALP	Single Code Entry: Serum alkaline phosphatase...	Date & Result:      	
Last ferritin	Single Code Entry: Serum ferritin  	Date & Result:      	
Transferrin Sat Index	Single Code Entry: Transferrin saturation index  	Date & Result:      	
Coded Ultrasound Report(s)	
: US scan of pancreas...	
Coded CT scan Report(s)	
: CT (computed tomography) of chest and abdomen...	
Last USS/CT if done and not shown above      	
Other relevant results	     	

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	

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 clinic 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
Allergies
Medication
Problems