Direct Access to Gastrointestinal Endoscopic Procedures (DAGE) pathways, symptom guidelines and referral guidelines

Direct Access to Gastrointestinal Endoscopic Procedures (D.A.G.E) Pathway

Western Health has developed a pathway to assist GPs to refer patients who meet the criteria for an urgent (Category 1 - i.e. within one month) Gastrointestinal Endoscopy. This pathway was previously known as the RAGE (Rapid Access to GI Endoscopy) Pathway, but has been modified to be consistent with the new gastroscopy and colonoscopy categorisation guidelines.

Two Pathways have been developed.

A Symptom Guide has also been developed to complement the pathways. This outlines the most important signs or symptoms associated with colorectal cancer and oesophageal or gastric cancer. DAGE symptom guide.

In referring a patient for direct access endoscopy the referrer should:

Inform the patient about the procedure.
Ensure they are willing to undergo the procedure.
Consider the ability of the patient to tolerate bowel preparation (if relevant) and the procedure.
Consider whether the patient will benefit if they are frail, have multiple co-morbidities or pre-existing malignancy. The procedure needs to be of overall benefit to the patient, and the benefits should outweigh the risks. This will be unique to each patient.
Ensure that if the patient has had a colonoscopy or gastroscopy in the preceding five years, that there is clear indication to repeat the procedure.

Essential Referral Requirements

Referral for direct access endoscopy must be made using the new gastrointestinal endoscopy referral form. From 1 May 2019, the previous referral forms (e.g RAGE) will no longer be accepted. New Victorian state-wide mandatory categorisation guidelines require that we obtain more specific information enabling us to meet the new triaging requirements.
All parts of the referral form must be complete for the referral to be accepted. Incomplete referrals will be returned to referring doctor.
Patients who have co-morbidities, medication considerations, complex medical issues, or who do not meet category 1 criteria, may not be suitable to proceed directly to endoscopy. We will use the information on the endoscopy referral form to arrange a clinic review for further assessment.

Referral Decisions and Acceptance Considerations
Referrals will only be accepted if they are submitted on the Gastrointestinal Endoscopy Referral Form and the referral form is complete.

Two versions of the new referral form exist:

1. GP Gastrointestinal Endoscopy Referral Form (form) is to be completed by:

GP's
Other referrers external to Western Health
Internal Western Health units that do not perform GI endoscopy procedures
Specialists from Western Health who do not perform GI endoscopy procedures

2. Gastrointestinal Endoscopy Referral Form is to be completed by referring practitioners from within WH Gastroenterology or WH surgical units who perform endoscopy procedures. The additional 2 pages on this form include more detailed procedure information and a consent form.

All referrals are triaged and bookings are offered based on clinical priority.

The guidelines used for clinical urgency categorisation are as follows:

Upper GI endoscopy Victorian categorisation guidelines: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/gastrointestinal-endoscopy-categorisation-guidelines-adults-2018
Colonoscopy Victorian categorisation guidelines: https://www2.health.vic.gov.au/about/publications/policiesandguidelines/colonoscopy-categorisation-guidelines

The colonoscopy guidelines make use of the NHMRC colonoscopy surverillance guidelines.

For the purposes of colonoscopy referrals, the Victorian DHHS has summarised these guidelines as follows:

Clinical Practice Guidelines for Surveillance Colonoscopy. This guideline should be used in conjunction with the endoscopy referral form when requesting colonoscopies for surveillance of colorectal cancer or colorectal polyps.

After completing the endoscopy referral form, please also attach the relevant supporting documents such as blood tests, radiology imaging results, previous endoscopy and histology reports. This information is critical to enabling us to triage the referral correctly. Without the necessary supporting information as requested on the referral form, it is likely that the referral will be rejected with a request for more information.

The endoscopy referral form and supporting documents should be faxed to the WH Endoscopic Services Booking office on fax number (03) 8345-7378.

Urgent referrals for bronchoscopy or EBUS should be referred to the on call Respiratory Registrar by phoning the Western Health switchboard on 8345 6666 and asking the staff to page the Respiratory Registrar.
Urgent referrals for advanced GI endoscopy procedures such as ERCP, EUS, EMR, complex polypectomy or luminal stenting, especially for patients who are currently inpatients at WH or at other hospitals, should be made to the Gastroenterology Advanced Endoscopy Fellow by phoning the Western Health switchboard on 8345 6666 and asking the staff to page the Endoscopy Fellow.

An important message to referring doctors: The time to procedures is affected by the referral demand we experience for procedures. At times, the volume of referrals is very high, and can result in delays to procedures.

Please note: If you are concerned about the delay for your patient, of if there is a deterioration in the patient's condition that may alter their triage category, please contact the Endoscopy Liaison nurse. You may then be requested to forward us this additional information for potential re-triaging.