Guidelines for a Colorectal Unit

A. Preamble

This document has been prepared to act as a discussion paper for the Council of the Colorectal Surgical Society of Australia and New Zealand. The items covered in these guidelines have been deliberately broad so as to cover as many of the possible scenarios that may exist in a hospital based Colorectal Surgery Unit.

Definitions have been combined with specifications in this document for the interest of simplicity, which provide the basis to minimum standards for a Colorectal Surgery Unit.

B. Surgical and Related Staff

A Colorectal Surgery Unit would be defined as a clinical team of at least (two) surgeons and related staff.

1. Surgeons
   
   The Unit should consist of a Unit Head and at least one other surgeon with the following specifications:
   
   
   • FRACS
   • Postgraduate experience in colorectal surgery, either within Australia or overseas
   • Experience in one or more of the following:
     
     Postgraduate experience, qualification or a Certificate of Training (or its equivalent) in one or more of the following:
     
     
     1. Colonoscopy
     2. Anorectal Physiology
     3. Endorectal Ultrasound
     4. Surgical Oncology
     5. Postgraduate Research Degree/Diploma
     6. Other Postgraduate Qualification relevant to colorectal surgery
        
        
   • Member of the Section of Colon and Rectal Surgery of the Royal Australasian College of Surgeons and Member of the Colorectal Surgical Society of Australia and New Zealand
   • Practices either exclusively colorectal surgery at this hospital or as a gastrointestinal surgeon where 80% of the patients managed are in colorectal surgery in this hospital.
     
     
2. Other Medical Staff
   
   The Unit shall have allocated to it:
   
   
   • An Advanced Trainee in General Surgery or its equivalent and/or a Colorectal Fellow
   • An HMO as either an Intern or second year level dedicated to the Unit.
   
   
3. Stomal Therapist
   
   The hospital shall have an appropriately qualified Stomal Therapist, if not full-time, at least on a regular basis to provide counselling and follow-up.
   
   
4. Nurse Unit Manager & Staff
   
   The Colorectal Unit should have access to one ward, or part thereof, to serve the majority of the patients admitted to that Unit. Some of the nursing staff on this ward should have a specific interest in colorectal surgery. Ideally, the ward should be shared with the Gastroenterology Unit and/or other Gastrointestinal Surgery Units of the hospital.
   
   
5. Ancillary Staff
   
   The Unit should have available, other allied health professionals to provide a spectrum of care (for example physiotherapy, occupational therapy and medical social worker, pastoral care and liaison psychiatry).

C. The Hospital and Supportive Services

To support a Colorectal Surgery Unit, the hospital involved should be equivalent size to, at least, a 300 bed metropolitan teaching hospital with availability of the following services:

1. Laboratory and Anatomical Pathology with a 24 hour frozen section service.
2. Intensive Care Unit and/or High Dependency Unit with the capacity to manage epidural anaesthesia.
3. Operating Theatres with a fully staffed recovery room.
4. Anaesthetic Department with at least one member of the anaesthetic staff with a particular interest in gastrointestinal surgery and pain management and regional anaesthesia.
5. Operating theatre nursing and technical staff with at least one team with a specific interest in Gastrointestinal Surgery.
6. A purpose built independent Endoscopy Suite or an Endoscopy Suite incorporated in the Operating Theatre with a dedicated Nurse Unit Manager and back-up staff.
7. Ancillary colorectal investigation office space and supportive staff available to conduct Endorectal Ultrasound and/or Anorectal Manometry.
8. Accident and Emergency Department adequately staffed and with equipment to perform emergency rigid endoscopy.
9. Radiological sciences and an accredited imaging department with facilities for x-ray screening, CT Scan, Visceral Angiography and Scintillation Scan.
10. Oncology and Radiotherapy access either within the hospital, network or region for ambulatory care or inpatient radiotherapy and chemotherapy. Specifically the availability of an inpatient consultative service in medical oncology and radiotherapy.

D. Specifications and Function of the Colorectal Surgery Unit

1. Day Surgery
   The hospital should have a Day Surgery Unit in the Operating Theatre.
   
   
2. Operating
   Each surgeon should have, at least, one half day operating per week dedicated to colorectal surgery.
   
   
3. Pre-admission Process
   The Unit should have access to a pre-admission clinic or similar arrangement to assess elective surgical patients to facilitate same day surgical admissions.
   
   
4. Outpatient or Private Office Assessment
   The Unit should have a dedicated outpatient clinic, with appropriate equipment for minor procedures or for surgeons to asses patients in a private office with similar equipment. Ideally, the surgeons of the Unit will attend the same outpatient clinic or share private office facilities.
   
   
5. After Hours Cover
   The Unit should provide an exclusive or consultative on-call service 24 hours a day, 7 days a week for Accident & Emergency and inpatient emergencies.
   
   
6. Weekly Ward Rounds and Meetings
   The Unit shall meet on a weekly basis to conduct meetings to discuss the patients, protocols or any other business combined at some stage with a visit to the patients (ward round).
   
   
7. Quality Assurance and Audit
   The Unit should be involved in a regular mortality and morbidity meeting, at least on a monthly basis with a six monthly or annual review. Quality assurance programmes (for example Clinical Indicators or quality projects) should become standard and reviewed at the weekly Unit meetings or audit meetings.
   
   
8. Research
   The Unit shall have an interest in research either by encouraging individual research projects within the hospital or collaborating with existing clinical research projects.
   
   
9. Academic Affiliation
   The Unit should have an affiliation with one of the University Medical Schools and be involved in Undergraduate Teaching Programmes.
   
   
10. Basic and Advanced Training in General/Colorectal Surgery
    Members of the Unit should be involved with the RACS activities to encourage surgical trainees in basic and advanced training in General and Colorectal Surgery. Some Units may have specific affiliation with the Section of colon and Rectal Surgery and provide six monthly rotations in Colon and Rectal Surgery for the Colorectal Fellow positions. The Unit should also encourage overseas trainees or colorectal surgeons to visit the Unit.
    
    
11. CME and Recertification
    The Unit head should be responsible for ensuring that the Guidelines provided by the Section of Colon and Rectal Surgery of the Royal Australasian College of Surgeons and the Colorectal Surgical Society of Australia and New Zealand are fulfilled and participate in CME activities.