Scheduling and choice

Booking processes must be robust to minimise late cancellations and failures to attend. To increase the chance of attendance an invitation for a primary screening test should be sent 2–3 weeks before the procedure is due, with an option for the patient to change the appointment if it is not convenient

Auditable outcome: Patient feedback on booking processes.  

Timelines 

A timely procedure is not critical in the context of primary screening but it is very important when endoscopy is performed following a previous positive screening test. A delayed procedure may not be critical biologically, but it can cause unnecessary anxiety for the screenee.

To ensure that patient anxiety is not unnecessarily increased, it is recommended that follow-up colonoscopy after positive screening be performed as soon as reasonably possible, but no later than within 31 days of referral (acceptable >90%, desirable >95%) 

Auditable outcome: Time taken from positive screening test to secondary endoscopic examination. If further pathological information is required before the decision to perform a colonoscopy, then the maximum and the desirable targets of four and two weeks, respectively, should be timed from the receipt of the pathology report. The pathology report should be delivered to the screening programme within two weeks.  

Environment 

The environment should be conducive to a good experience and efficient processing. It should be physically comfortable, offer privacy and there should be facility to hold private conversations with screenees and their relatives. The reception and assessment areas should be separate from recovery facilities 

Auditable outcomes: patient feedback on environment and patient turn around times. 

During the procedure 

There is an increasing body of evidence demonstrating unacceptable miss rates of cancer following colonoscopy. Miss rates vary between endoscopists suggesting that care with the examination and technique play a key role in ensuring cancer is not missed.

Endoscopists must have a mix of technical, knowledge and judgement competencies to identify and successfully remove high-risk lesions. Ideally they will perform a complete examination quickly, safely and with minimal discomfort, leaving time to properly inspect the colon, and safely remove and retrieve lesions. They will identify all abnormal areas, characterise them and make a judgement of what to do. They will then, if it is appropriate to do so, safely remove and retrieve all neoplastic lesions 

Providing such high-quality and safe endoscopy requires a team approach with appropriate equipment immediately to hand. The nursing support team must ensure the patient is comfortable and has stable observations to allow the endoscopist to devote his attention to the procedure. The nurses also provide important technical support ensuring endoscopy equipment is serviceable and that all the necessary accessories are readily available. Finally they play an important role supporting the endoscopist during therapeutic procedures. Both endoscopist and nurse should regularly reflect on their practice together with pathology and surgical teams in order to optimise patient outcomes. 

High-quality and safe endoscopy also depends on adequate maintenance of equipment, and on an adequate supply of accessories for the range of procedures undertaken in the department. This should include equipment to manage complications of excision of high-risk lesions such as bleeding and in some instances, perforation. Endoscopy equipment is expensive and is subject to frequent and occasionally heavy use. It is essential that equipment be maintained by competent staff. Maintaining and repairing old endoscopic equipment is often more expensive than replacing it. 

  It is not appropriate for this chapter to provide a manual of how to perform colonoscopy and detect and remove high-risk lesions. However, there have been significant advances in decontamination processes, technique and technology in recent years. Because these advances might affect service provision and patient outcomes, it is considered important to review the evidence for their effectiveness.

Technological improvements have promised easier insertion of endoscopes and better visualisation of the mucosa. However, despite the potential of advances in endoscopic technology, they cannot be recommended for routine use until they have been demonstrated to be of benefit in clinical practice. The following sections provide an overview of the current state of these technologies and best practice for safe, high-quality endoscopy.