Download TCFHT-MD01_Fecal Occult Blood Test

MEDICALDIRECTIVE
Title:
ActivationDate:
NextReview:
Sponsoring/Contact
Person(s)
(name,position,
contactparticulars):
FecalOccultBloodTest
01-01-2014
01-01-2016
Number:
Reviewed:
TCFHT-MD01
01-01-2015
PaulinePariser,MD,LeadPhysician
790BaySt.,Suite300,Toronto
416-960-1366
ShazmahHussein,RN
790BaySt.,Suite300,Toronto
416-960-1366
SherryKennedy,ExecutiveDirector–[email protected]
790BayStreet,Suite306,Toronto
416-260-1315,x307
AppendixAttached:!Yes"No
Orderand/orDelegatedProcedure:
ImplementersmayorderaFecalOccultBloodTest(FOBT)forcolorectalcancer(CRC)screeningin
accordancewiththeconditionsidentifiedinthisdirective.
AppendixAttached:"Yes☐ No
RecipientPatients:
Title:AppendixA–AuthorizerApprovalForm
Recipientsmust:
• BeactivepatientsofaTCFHTprimarycareproviderwhohasapprovedthisdirectivebysigning
theAuthorizerApprovalForm
• Be50yearsofageorolder*
• Meettheconditionsidentifiedinthisdirective
*Eligibleiftheyare49yearsoldandtheir50thbirthdayiswithin60daysofapplicationofthe
directive
AppendixAttached:"Yes☐ No
AuthorizedImplementers:
Title:AppendixB–ImplementerApprovalForm
Implementer must be a TCFHT employed Regulated Health Care Providers or Physician Assistant
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(underthesupervisionofaphysician).
ImplementersmusthavecompletedthefollowingtrainingandsigntheImplementerApprovalForm:
1) ReviewtheentireHealthCareProfessionalssectionoftheOntarioMinistryofHealthand
LongTermCareColonCancerCheckprogramwebsite,accessiblefrom:
http://health.gov.on.ca/en/pro/programs/coloncancercheck/
2) ReviewthefollowingColonCancerCheckdocuments:
a. ColonCancerCheck.(2008).ColorectalCancerScreening,accessiblefrom:
http://health.gov.on.ca/en/pro/programs/coloncancercheck/docs/ccc_foldout_20080
606.pdf
b. ColonCancerCheck.(2008).Riskassessment,accessiblefrom:
http://health.gov.on.ca/en/pro/programs/coloncancercheck/docs/ccc_refcard_20080
606.pdf
3) Reviewthefollowingarticles,accessiblefromhttp://www.UptoDate.com:
a. Fletcher,R.H.(2013).Screeningforcolorectalcancer:Strategiesinpatientsat
averagerisk.
b. Fletcher,R.H.(2013).Testsforscreeningforcolorectalcancer:Stooltests,radiologic
imagingandendoscopy.
AppendixAttached:"Yes☐ No
Indications:
Title:AppendixC–CRC(FOBT)ScreeningRequisition
ImplementersmayorderaColonCancerCheckFOBTforeligiblepatientswhoare50yearsoldand
older*whohaveaverageriskofCRCaccordingtotheirhealthinformationintheEMRusinga
MinistryofHealthandLong-TermCareLaboratoryRequisition.
Contraindications:
• PatientswhohaveapersonalhistoryofCRC(ColonCancerCheck,2008a).
• PatientswhohaveafamilyhistoryofCRC(ColonCancerCheck,2008a).
• Patientswhohaveapersonalhistoryofinflammatoryboweldisease(ulcerativecolitisorCrohn’s
disease)(Fletcher,2013a).
• PatientswhohaveaverageriskforCRC,andhaveanormalcolonoscopyonfilewithinthelast10
years(ColonCancerCheck,2008a,Fletcher,2013b).
*Eligibleiftheyare49yearsoldandtheir50thbirthdayiswithin60daysofapplicationofthe
directive
AppendixAttached:"Yes☐ No
Consent:
Title:AppendixD–Turning50CRCScreening(FOBT)
Letter
ThepatienthasenrolledwiththeirproviderattheTaddleCreekFHT.Therefore,consenttoreceive
healthinformationandnotificationofscreeningeligibilityisimplied.Aletterwillaccompanythe
FOBTkitinthemail,whichwillencouragethepatienttocontacttheirprovidershouldtheyhave
questions.OncereceivingtheFOBTkitinthemail,thepatientcompletesthetestbyhisorherown
volition.
AppendixAttached:☐ Yes"No
GuidelinesforImplementingthe
Order/Procedure:
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ThepurposeofthismedicaldirectiveistoenhanceTCFHTpatients’accesstoCRCscreening,whichis
inaccordancewiththe“CancerCareOntarioGuidelinesforBreast,Cervical,&ColorectalCancer
Screening”(CancerCareOntario,2013).
AppendixAttached:☐ Yes"No
DocumentationandCommunication:
Implementerswilldocumentthattheyhavereviewedaneligiblepatient’sEMRandorderedanFOBT
inthe“Turning50CRC(FOBT)ScreeningProgram”EncounterAssistant.
TheimplementerwillsendamessageinPracticeSolutionstothepatient’sprimarycareprovider,
indicatingthattheyhaveorderedanFOBTforthepatient.
Theimplementerwillsendadelayedmessagetothemselvesin60daystofollowupwiththepatient
viaphoneiftheFOBTtestisnotcompletedwithinthistimeframe.Afterthis60dayfollowupphone
call,nofurtherfollowupisrequired.
AppendixAttached:☐ Yes"No
ReviewandQualityMonitoringGuidelines:
•
Routinereviewwilloccurannuallyontheanniversaryoftheactivationdate.Reviewwillinvolve
acollaborationbetweentheauthorizingprimarycareprovidersandtheapprovedimplementers.
•
Ifnewinformationbecomesavailablebetweenroutinereviews,suchasthepublishingofnew
clinicalpracticeguidelines,andparticularilyifthisnewinformationhasimplicationsfor
unexpectedoutcomes,thedirectivewillbereviewedbyanauthorizingprimarycareproviderand
amimimumofoneimplementer
•
Atanysuchtimethatissuesrelatedtotheuseofthisdirectiveareidentified,TCFHTmustact
upontheconcernsandimmediatelyundertakeareviewofthedirectivebytheauthorizing
primarycareprovidersandtheauthorizedimplementers.
Thismedicaldirectivecanbeplacedonholdifroutinereviewprocessesarenotcompleted,orif
indicatedforanadhocreview.Duringthehold,implementerscannotperformtheprocedures
underauthorityofthedirectiveandmustobtaindirect,patient-specificordersfortheprocedure
untilitisrenewed.
•
References:
CancerCareOntario.(2013).CancerCareOntarioguidelinesforbreast,cervical,&colorectalcancer
screening.Retrievedfromhttps://www.cancercare.on.ca/common/pages/UserFile.aspx?
fileId=273767
ColonCancerCheck.(2008a).Riskassessment.Retrievedfromhttp://health.gov.on.ca/en/pro/
programs/coloncancercheck/docs/ccc_refcard_20080606.pdf
ColonCancerCheck.(2008b).Colorectalcancerscreening.Retrievedfromhttp://health.gov.on.ca/
en/pro/programs/coloncancercheck/docs/ccc_foldout_20080606.pdf
Fletcher,R.H.(2013a).Screeningforcolorectalcancer:Strategiesinpatientsataveragerisk.
Retrievedfromhttp://www.uptodate.com
Fletcher,R.H.(2013).Testsforscreeningforcolorectalcancer:Stooltests,radiologicimagingand
endoscopy.Retrievedfromhttp://www.uptodate.com
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NOTE:
ThismedicaldirectiveisbasedonTCFHT’spreviousmedicaldirectivePH-1entitled,“Preventive
Health,”whichrequiredrevisioninformattingtoreflectthegrowthoftheTCFHTorganization.
ThemajorityofthecontentofPH-1hasremainedthesamefortherevisedTCFHT-MD01version.
Therefore,allapprovedImplementersandAuthorizersformedicaldirectivePH-1“Preventive
Health”havegrandfatheredapprovalforTCFHT-MD01“FecalOccultBloodTest.”
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AppendixA:
AuthorizerApprovalForm
NameSignatureDate
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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_______________________________________________________________________________
AppendixB:
ImplementerApprovalForm
Tobesignedwhentheimplementerhascompletedtherequiredpreparation,andfeeltheyhavethe
knowledge,skill,andjudgementtocompetentlycarryouttheactionsoutlinedinthisdirective.
NameSignatureDate
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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AppendixC:
PreventiveHealth–CRCScreeningRequisition
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Laboratory Use Only
Ministry of Health
and Long-Term Care
Laboratory Requisition
Requisitioning Clinician / Practitioner
Name
Address
Clinician/Practitioner’s Contact Number for Urgent Results
(
Clinician/Practitioner Number
CPSO / Registration No.
yyyy
Health Number
Version
Sex
Province Other Provincial Registration Number
Third Party / Uninsured
OHIP/Insured
yyyy
Date of Birth
mm
dd
Patient’s Telephone Contact Number
WSIB
Additional Clinical Information (e.g. diagnosis)
dd
F
M
Check ( " ) one:
Service Date
mm
)
(
)
Patient’s Last Name (as per OHIP Card)
Patient’s First & Middle Names (as per OHIP Card)
Copy to: Clinician/Practitioner
Last Name
Patient’s Address (including Postal Code)
First Name
Address
Note: Separate requisitions are required for cytology, histology / pathology and tests performed by Public Health Laboratory
X
Biochemistry
Glucose
X
Hematology
X
Viral Hepatitis (check one only)
CBC
Acute Hepatitis
HbA1C
Prothrombin Time (INR)
Chronic Hepatitis
TSH
Immunology
Creatinine (eGFR)
Pregnancy test (Urine)
Immune Status / Previous Exposure
Specify:
Hepatitis A
Uric Acid
Mononucleosis Screen
Sodium
Rubella
Potassium
Prenatal: ABO, RhD, Antibody Screen
(titre and ident. if positive)
Random
Fasting
Chloride
CK
Repeat Prenatal Antibodies
ALT
Alk. Phosphatase
Microbiology ID & Sensitivities
(if warranted)
Bilirubin
Cervical
Albumin
Vaginal
Lipid Assessment (includes Cholesterol, HDL-C, Triglycerides,
calculated LDL-C & Chol/HDL-C ratio; individual lipid tests may
be ordered in the “Other Tests” section of this form)
Vaginal / Rectal – Group B Strep
Vitamin B12
GC (specify source):
Ferritin
Sputum
Albumin / Creatinine Ratio, Urine
Throat
Urinalysis (Chemical)
Wound (specify source):
Hepatitis B
Hepatitis C
or order individual hepatitis tests in the
“Other Tests” section below
Prostate Specific Antigen (PSA)
Total PSA
Free PSA
Specify one below:
Insured – Meets OHIP eligibility criteria
Uninsured – Screening: Patient responsible for payment
Vitamin D (25-Hydroxy)
Insured – Meets OHIP eligibility criteria:
osteopenia; osteoporosis; rickets;
renal disease; malabsorption syndromes;
medications affecting vitamin D metabolism
Uninsured – Patient responsible for payment
Chlamydia (specify source):
Other Tests – one test per line
Urine
Neonatal Bilirubin:
Child’s Age:
hours
days
Stool Culture
Clinician/Practitioner’s tel. no. (
)
Stool Ova & Parasites
Patient’s 24 hr telephone no.
)
Other Swabs / Pus (specify source):
(
Therapeutic Drug Monitoring:
Specimen Collection
Time
24 hour clock
Name of Drug #1
Name of Drug #2
Date
yyyy/mm/dd
Fecal Occult Blood Test (FOBT) (check one)
Time Collected #1
hr.
#2
hr.
Time of Last Dose #1
hr.
#2
hr.
FOBT (non CCC)
Time of Next Dose #1
hr.
#2
hr.
Laboratory Use Only
ColonCancerCheck FOBT (CCC) no other test can be ordered on this form
I hereby certify the tests ordered are not for registered in or
out patients of a hospital.
X
Clinician/Practitioner Signature
4422–84 (2010/09)
Date
7530–4581
!Queen’s Printer for Ontario, 2010
AppendixD:
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Turning50CRCScreening(FOBT)Letter
ImplementerName
ImplementerTaddleCreekFHTContactInformation
Date
DearPatient’sFirstName,
IamtheRegisteredNursethatworkswithyourprimarycareprovider.Ourrecordsshowthatyouwillsoonbe
turning50yearsold.HappyBirthday!Thisisanimportantmilestoneinyourlifeandanopportunitytofocus
onyourhealth.Aspartofyourprimarycareteam,I’mcommittedtohelpingyoubeashealthyaspossible.A
keypartofmaintainingyourhealthisthepreventionandscreeningofchronicdiseases.Ourrecordsshowthat
youaredueforcolorectalcancerscreening:
ColorectalCancerScreening–Adultsaged50to74areencouragedtodotheFecalOccultBloodTest(FOBT)
every2years.IhaveincludedanFOBTkitinthispackage.Pleasereviewtheinstructions,dotheFOBTtest
assoonasyoucan,andpopthekitinthemailwhenyou’redone.FOBThasbeenfoundtodecreasetherisk
ofdyingfromcolorectalcancer.Apersonwithcolorectalcancerhasa90%chanceofbeingcuredifthecancer
iscaughtearlywithscreening.
Gotowww.youtube.comandsearch“HomeScreeningforColonCancer(FOBT)”formoredetails.
Note:Ifyouhaveapersonalorfamilyhistoryofcolorectalcancer,FOBTscreeningmaynotbeappropriate.In
thiscase,pleasecontactustodiscusswhatscreeningisrecommendedforyou.
Ifin2monthswehavenotreceivedyourFOBTresults,Iwillcallyoutofollowup.Aspartofyourprimarycare
team,Iappreciatetheopportunitytoworkwithyoutoenhanceyourhealthandpreventillness.Shouldyou
haveanyquestionsorconcerns,feelfreetocontactme.
Yourstruly,
ImplementerNameandSignature
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