General Hospital Demographics

1,537 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,537
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
4
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

General Hospital Demographics

  1. 1. UK IBD Audit 2006 National Results for the Organisation & Process of IBD Care in the UK Prepared by The UK IBD Audit Steering Group on behalf of• Association of Coloproctology of Great Britain and Ireland• British Society of Gastroenterology• Clinical Effectiveness & Evaluation Unit, Royal College of Physicians of London• National Association for Colitis and Crohn’s Disease February 2007
  2. 2. REPORT PREPARED BY:Dr Keith LeiperConsultant Gastroenterologist, Royal Liverpool University Hospital & Clinical Director for the UK IBDAuditMr Derek LoweMedical Statistician, Clinical Effectiveness and Evaluation Unit, Royal College of PhysiciansMr Richard DriscollDirector, National Association for Colitis and Crohn’s Disease (NACC)Miss Asha SenapatiConsultant Surgeon, Queen Alexandra Hospital, PortsmouthProfessor Jonathan RhodesProfessor of Medicine, University of LiverpoolMr Calvin DownIBD Audit Project Manager, Clinical Effectiveness and Evaluation Unit, Royal College of PhysiciansMiss Nancy PurseyIBD Audit Project Co-ordinator, Clinical Effectiveness and Evaluation Unit, Royal College of PhysiciansACKNOWLEDGEMENTSThe Royal College of Physicians of London and the UK IBD Audit Steering Group (Appendix 1) thankand acknowledge all who have participated in the piloting and development of the audit since thebeginning of the Project.The web based data collection tool was developed by Netsolving Ltd.Thanks are due to the many people who have participated in the UK IBD Audit 2006. It is recognisedthat this has involved many individuals spending time over and above an already heavy workload with nofinancial recompense.Thanks are also due to • The Health Foundation who fund the UK IBD Audit • The Association of Coloproctology of Great Britain and Ireland • The British Society of Gastroenterology • The National Association for Colitis and Crohn’s Disease (NACC) • All those who contributed to organising the collection, retrieval and input of data including audit, IT and coding staff in addition to the members of the clinical teams.
  3. 3. UK IBD Audit 2006 ReportCONTENTS PageExecutive summary 5Introduction 15Aims of the Audit 15Availability of this report in the public domain 15Methods 16Standards in the audit 16Data collection tool 16Definition of a ‘site’ 16Recruitment 16Selection criteria for the patient cohorts (ICD-10 codes) 17Data reliability 17Presentation of results 18RESULTSSection 1. Key National Results for England, Northern Ireland, 19Scotland and WalesOrganisation and Structure 19Ulcerative Colitis Inpatients 20Crohn’s Disease (inpatients & outpatients) 21Section 2. Organisation and Structure of IBD services as at 1st June 232006General Hospital Demographics 23Inpatient activity 24Gastroenterology services 24Colorectal services 26Multi-disciplinary working 26Dietetics & Nutritional services 27Outpatient services 28Patient information 28Monitoring of established immunosuppressive therapy 29IBD support services 29Management of Ulcerative Colitis 29Interactions between hospital and patients and patient groups 30Section 3. Clinical Audit: Ulcerative Colitis (Inpatient) 31Patient demographics 31Admission 32Co-morbidity 33Inpatient mortality 33Mortality after discharge 33Length of stay 34Assessment: patient history 34Assessment: severity of disease 35Assessment: endoscopic assessment 36Monitoring of Colitis post admission – general information 37Monitoring of Colitis post admission – radiology 39Medical intervention – steroid therapy 40Medical intervention – other therapies 41
  4. 4. UK IBD Audit 2006 ReportMedical intervention - initiating ciclosporin therapy 42Medical intervention – monitoring ciclosporin therapy 43Surgical intervention 44Surgical complications 46Discharge arrangements 46Section 4. Clinical Audit: Crohn’s Disease (Inpatient) 48Patient demographics 48Admission 48Admitting speciality 49Inpatient mortality 50Mortality after discharge 50Length of stay 51Co-morbidity 51Medication on admission 51Smoking status 52Patient history 52Assessment: severity of disease 53Assessment: exclusion of infection 54Assessment: documentation of sepsis 54Assessment: imaging 55Assessment: weight assessment & dietetic support 56Assessment: use of anti-thrombotic therapies 57Medical intervention - steroid therapy 57Medical intervention – blood transfusion 57Medical intervention – treatment initiation with anti-TNF during admission 58Surgical intervention 58Post-operative prophylactic therapy 60Discharge arrangements 615. Clinical Audit: Crohn’s Disease (Outpatient) 62Patient history 62Assessment of Crohn’s activity 63Smoking status 64Monitoring of immunosuppressive therapy 64Use of corticosteroids 65Use of anti-TNF therapy 66Appendices1. Membership of the UK IBD Audit 2006 Steering Group 672. Copies of Audit Proformas 693. Pilot sites 924. List of hospitals that submitted data to the audit 935. List of hospitals that did not submit data to the audit 966. UK IBD Steering Group list of IBD Standards 97
  5. 5. UK IBD Audit 2006 Executive SummaryBackgroundThe UK IBD Audit is the first UK-wide audit performed within gastroenterology. The 1st Round of theUK Inflammatory Bowel Disease Audit was conducted from September 2006 to December 2006.National audit data could support the self assessment requirements of the Healthcare Commission.Although ignored by the National Service Framework program, gastroenterological conditions arecommon and after cardiac and respiratory disease are the third most common reason for acute medicalemergency admissions. IBD includes Crohn’s Disease and Ulcerative Colitis, different disorders, but withconsiderable overlap in terms of health service care. Together, they affect about 1 in 400 of thepopulation. They present in late adolescence or early adult life so typically affect people who are trying toearn a living and/or raise a family. IBD accounts for 0.3% of absences from work in the UK with anestimated loss of £115 million in productivity per year. At least 80% of Crohn’s disease patients needsurgery at some time, as do 25% of patients with ulcerative colitis. There are about 27,000 admissions peryear for exacerbations of IBD and admissions are associated with significant mortality. Many deathsoccur around the time of surgery and data indicates that young people are disproportionately representedamongst those deaths. Data from individual hospitals has shown a marked variation in mortality ratesacross the UK.The UK IBD Audit seeks to improve the quality and safety of care for IBD patients in hospitalsthroughout the UK by auditing individual patient care, service resources and organisation against nationalstandards. The British Society of Gastroenterology has recently published national evidence basedguidelines that cover all the clinical aspects of management of IBD.Audit Aims 1. Assess the current structure and organisation of care for those patients with IBD 2. Assess the processes and outcomes of care delivery (inpatient and outpatient) in IBD 3. Enable Trusts to compare their performance and quality of care against national standards 4. Identify resource and organisational factors that may account for variations in care 5. Facilitate, develop and institute an intervention strategy to improve quality of patient care. 6. Repeat the audit to prove that change has occurred 7. Establish measures that healthcare services can use beyond the study to compare quality of IBD services 8. Develop a sustainability programme to maintain quality of patient care.This report addresses aims 1, 2, 3 & 4 enabling each site to compare or benchmark their performanceagainst national statistics.Audit OrganisationThe audit is a collaborative partnership between Gastroenterologists (the British Society ofGastroenterology), Colorectal Surgeons (the Association of Coloproctology of Great Britain and Ireland),Patients (the National Association for Colitis and Crohn’s Disease) and Physicians (the Royal College ofPhysicians of London). It is funded by a grant from the Health Foundation as part of their Engaging withQuality Initiative which aims to improve the quality of clinical care by engaging clinicians in qualityimprovement. The audit is a four-year, nation-wide, full cycle comparative audit with initial audit,dissemination, change implementation and re-audit. 5
  6. 6. UK IBD Audit 2006 ReportThe audit is co-ordinated by the Clinical Effectiveness and Evaluation unit (CEEu) of the Royal Collegeof Physicians of London. Each hospital identified a lead from their IBD service and data were collectedby hospitals using a standardised method. Data collection was overseen at site level by a lead agreedwithin the site IBD service. The audit was guided by a multidisciplinary IBD Audit Steering Group(Appendix 1) which oversaw the preparation, conduct, analysis and reporting of the audit.Who participated?281 acute hospitals that admit patients with Inflammatory Bowel Disease (IBD) in England, NorthernIreland, Scotland and Wales (plus the Isle of Man and the Channel Islands) were invited to take part. 200sites submitted data (England 159, Northern Ireland 10, Scotland 14, Wales 15, Islands 2). Of these 200sites, 12 were Trust-wide sites combining 2 hospitals with a total of 212 hospitals entering data.We aimed to get 80% of applicable Acute Hospitals in the UK - a tough but realistic target for a disciplinewithout any previous record of national audit- and achieved 75% participation. This response wasachieved through the hard work and time-commitment of clinical teams involved in the management ofpatients with IBD.The audit of the organisation of IBD services was ‘as of 1st June 2006’ (together with activity data from1st June 2005 to 31st May 2006) and 181 sites submitted data.For individual patient care, 40 consecutive inpatient case notes were audited (20 Crohn’s Disease and 20Ulcerative Colitis) admitted from 1st June 2006 working backwards as far as 1st June 2004. For bothUlcerative Colitis (UC) and Crohn’s Disease (CD), inpatient details were audited and for CD the lastoutpatient visit prior to admission was audited. In total, data were collected for 2767 Ulcerative Colitispatients (from 180 sites), median (IQR) of 19 (11-20) per site, and for 2914 Crohn’s Disease patients(from 185 sites), median (IQR) of 19 (12-20) per site.ResultsThe complete results of the audit are presented in full in this audit report. The Executive Summaryfocuses on the Key messages derived from the full report in the opinion of the UK IBD Audit SteeringGroup.Key MessagesKey messages are summarised below (with histograms illustrating site variation). These include areaswhere improvement of care across the UK is urgently required. 6
  7. 7. UK IBD Audit 2006 ReportOrganisation & Structure of hospital IBD ServicesInpatient activity and organisation of services • Multidisciplinary team working functions well with timetabled meetings between gastroenterologists and surgeons in 74% of sites. Joint or parallel medical-surgical clinics occur in only 47%. Comment: IBD MDT meetings should occur regularly at all sites. • Hospitals vary considerably in their yearly inpatient activity in IBD; median (Interquartile range [IQR]) 50 (25-105) range 1-481 for Ulcerative Colitis and 61 (30-111) range 2-609 for Crohn’s Disease. Comment: some smaller hospitals may need to interact with larger ones to provide a comprehensive inpatient IBD service. • 44% of sites have no IBD clinical nurse specialist(s). Amongst those with specialist nurses, the median number of sessions dedicated to IBD care is 6 per week. Comment: IBD clinical nurse specialist(s) service needs to be expanded to include all sites caring for patients with IBD. • 33% of sites did not have a dedicated gastroenterology ward (medical or surgical). Comment: a dedicated gastroenterology ward or ward area should be identifiable at each site. • There are not enough toilets with a median 4.5 beds per toilet. Comment: there should be a maximum of 3 beds per toilet. • Provision of dietetic services is poor with a median of 2 (IQR 0-5) sessions per week dedicated to gastroenterology. Comment: IBD patient surveys show dissatisfaction with the lack of dietetic services. There needs to be improvement in the provision of these services. • Ileo-anal pouch procedures are performed in most sites (72%) but the volume of surgery is low (median 4 [IQR 2-7] per year). Comment: hospitals with a low volume of pouch surgery should consider referring to hospitals with a larger volume of pouch surgery. • Only 34% of sites have a searchable IBD database. Comment: Provision of databases need to improve across the UK to facilitate patient care (e.g. colorectal cancer surveillance, immunosuppressive therapy monitoring) and auditInteractions between hospitals and patients and patient groups • Open forum or other meetings with patient groups are uncommon in the UK with only 30% of sites involved in these. Comment: IBD teams should be encouraged to set up meetings with patient groups, perhaps on a regional basis.IBD Support services • Only 21% of sites have pathways for direct access to psychological support. Comment: direct referral pathways should be available for IBD teams to refer directly to psychological support services. 7
  8. 8. UK IBD Audit 2006 ReportUlcerative Colitis Inpatients: • 31% of patients admitted with Ulcerative Colitis are not transferred to a specialist gastroenterology ward (medical, surgical or joint). Comment: Triage systems for IBD should be established to ensure that admitted patients are under the care of the relevant specialty team. • Inpatient mortality was 1.6% (45 patients). 25 deaths were directly related to Ulcerative Colitis, including 15 that occurred in patients who had surgery. Comment: further analyses are being performed to investigate possible correlations with mortality. • Stool culture was done in 59% of patients (CDT done in 47%). Comment: both stool culture and CDT should be performed in all patients admitted with active Ulcerative Colitis. • For new diagnoses of Ulcerative Colitis, endoscopic evaluation was done a median of 2 (IQR 1-5) days from admission. Histology was reported a median of 5 (IQR 2-7) days after endoscopic procedure. Comment: In many sites there is a delay in obtaining reported histology. For suspected new diagnosis of Ulcerative Colitis admitted to hospital, histology should be reported within 5 days of biopsies being taken. • 40% of Ulcerative Colitis inpatients did not receive prophylactic heparin. Comment: in-patients with Ulcerative Colitis should receive prophylactic heparin. • For those Ulcerative Colitis patients failing to respond to high dose steroids (high CRP and high stool frequency after 3 days therapy), surgery was the next therapy in 42%, 25% had ciclosporin and 4% anti-TNF-α therapy. Comment: rescue medical therapy (ciclosporin or anti-TNF-α therapy) was infrequently used. This an area in which participation in clinical trials is needed. Functional clinical trials networks would be beneficial. • The decision to operate was made by a consultant colorectal surgeon in 77% of elective operations and 81% of emergency operations. 92% elective and 77% emergency operations were performed or assisted by consultant colorectal surgeons. Comment: consultant colorectal surgeons should be involved in the decision to operate and perform (or assist) operations for inflammatory bowel diseaseCrohn’s Disease Inpatients: • Smoking status was not documented in 15% of cases. Comment: smoking cessation support is an important aspect in treating people with Crohn’s Disease. • Only 52% of patients admitted with Crohn’s Disease were weighed and only 37% were seen by a dietitian. Comment: patients admitted with Crohn’s Disease should be weighed and seen by a dietitian. • Prophylactic anti-thrombotic therapy was not given in 38% of cases. Comment: in-patients with Crohn’s Disease should receive prophylactic heparin. • For elective surgery, 12% of cases were done laparoscopically/ laparoscopically-assisted. Comment: There is marked variation geographically in the provision of laparoscopic surgery for IBD. Laparoscopic surgery should be available as an option for patients with Crohn’s Disease requiring resectional surgery. 8
  9. 9. UK IBD Audit 2006 Report • In 49% of cases where resectional surgery was performed for Crohn’s Disease, post-operative prophylactic therapy was not given. Comment: prophylactic therapy to try to reduce recurrence should be discussed with Crohn’s Disease patients having resectional surgery with anastomosis.Crohn’s Disease Outpatient care • Established immunosuppressive therapy was monitored by full blood count at least 3 monthly in around 90% of cases. Comment: full blood count should be monitored at least 3 monthly for all patients on established immunosuppressive therapy. • 46% of patients receiving systemic corticosteroids received continuous therapy for more than 3 months. 12% of these received anti-TNF- therapy. Comment: Prolonged use of steroid therapy is of no benefit in maintaining remission in Crohn’s Disease, increases the risk of septic complications and is associated with an increased mortality. Prolonged use of steroids (oral prednisolone or budesonide) should be avoided. • Only 45% of patients on systemic steroids were prescribed bone protection agents and only 18% had bone densitometry performed within 12 months of initiation of systemic corticosteroids. Comment: there is inadequate prophylactic bone protection therapy given for patients on systemic steroids and inadequate screening for osteoporosis.Research • Only two Ulcerative Colitis patients failing high dose steroids participated in any clinical trial and only ten Crohn’s Disease patients were on any trial drug on admission, both <1% participation. Comment: There seems to be infrequent participation in clinical research - functional clinical trials networks would be beneficial. 9
  10. 10. UK IBD Audit 2006 Report Site variation histograms for Key IndicatorsBeds per lavatory on the ward.Median 4.5, Inter-Quartile Range 3.0-6.0, n=118 sites with a dedicated Gastroenterology ward.Note that two outliers have been excluded from the histogram 25 20 15 Sites 10 5 0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Gastroenterology Beds Per LavatoryNumber of IBD specialist nurse sessions.Median 1, Inter-Quartile Range 0-6 sessions, n=170 sitesNote that one outlier has been excluded from the histogram 90 80 70 60 Sites 50 40 30 20 10 0 0 5 10 15 20 25 Sessions of Specialist Nurse time dedicated to IBD care per week 10
  11. 11. UK IBD Audit 2006 ReportNumber of sessions of dietetic supportMedian 2, Inter-Quartile Range 0-5, n=171 sites 60 50 40 Sites 30 20 10 0 0 5 10 15 20 25 Dietetic sessions per week dedicated to GI disorders% of IBD patients (UC or Crohn’s) with diarrhoea who had standard stool culture and CDTperformed.Median 42%, Inter-Quartile Range 23-56%, n=178 sites 25 20 15 Sites 10 5 0 0 10 20 30 40 50 60 70 80 90 100 % stools sent for standard culture AND for CDT (UC+Crohns patients) 11
  12. 12. UK IBD Audit 2006 Report% of IBD admissions (UC & Crohn’s cases) with prophylactic heparinMedian 62%, Inter-Quartile Range 46-77%, n=179 sites 20 Sites 15 10 5 0 0 20 40 60 80 100 % for prophylactic heparin (UC +Crohns cases)% of operations done or assisted by a consultant colorectal surgeon (UC & Crohn’s cases)Median 83%, Inter-Quartile Range 69-95%, n=179 sites 50 40 30 Sites 20 10 0 0 10 20 30 40 50 60 70 80 90 100 % for consultant colorectal surgeon operating or assisting (UC+Crohns) 12
  13. 13. UK IBD Audit 2006 Report% with Bone protection agents prescribed alongside oral steroids (UC cases at discharge)Median 40%, Inter-Quartile Range 20-64%, n=179 sites 25 20 15 Sites 10 5 0 0 10 20 30 40 50 60 70 80 90 100 % Bone protection agents prescribed (UC)% of patients at any point taking oral corticosteroids for > 3 months (Crohn’s outpatient cases)Median 43%, Inter-Quartile Range 20-64%, n=175 sites 40 30 Sites 20 10 0 0 10 20 30 40 50 60 70 80 90 100 % Taking oral corticosteroids for Crohns Disease continuously for >3M 13
  14. 14. UK IBD Audit 2006 Report% with weight measured during admission (Crohn’s Disease inpatient cases)Median 50%, Inter-Quartile Range 31-71%, n=185 sites 20 15 Sites 10 5 0 0 10 20 30 40 50 60 70 80 90 100 % Weight measured during admission (Crohns Disease)Next steps in the UK IBD Audit process - 2007 and beyondDuring 2007 multi-disciplinary regional meetings will stimulate local discussion of results and look forlocal solutions to identified problems. This approach is known to work but the project would like toaccelerate the pace of change. A “Model” Action Plan for IBD services will be developed by the Projectteam and Steering Group in conjunction with hospital teams. This will be an interactive process with theIBD community nationwide.A subgroup of sites will then be selected at random to receive intensive support with action planning. Itis hoped that the progress of this subgroup can be compared to the progress of other hospitals in changesto organisational structure, processes and outcome. Round 2 of the audit is planned for 2008-2009 inwhich both organisational and clinical care audits will be repeated. The number of questions will bereduced in the 2nd round of audit and will be largely based on the key messages above. The project hopesto see change for each of these dimensions. 14
  15. 15. UK IBD Audit 2006 ReportINTRODUCTIONAlthough ignored by the National Service Framework program, gastroenterological conditions arecommon and after cardiac and respiratory disease are the third most common reason for acute medicalemergency admissions1. IBD includes Crohn’s Disease and Ulcerative Colitis, different disorders, butwith considerable overlap in terms of health service care. Together, they affect about 1 in 400 of thepopulation. They present in late adolescence or early adult life so typically affect people who are trying toearn a living and/or raise a family. IBD accounts for 0.3% of absences from work in the UK with anestimated loss of £115 million in productivity per year2. At least 80% of Crohn’s Disease patients needsurgery at some time, as do 25% of patients with ulcerative colitis. There are about 27,000 admissions peryear for exacerbations of IBD3 and admissions are associated with significant mortality4. Many deathsoccur around the time of surgery and data indicates that young people are disproportionately representedamongst those deaths5.The British Society of Gastroenterology has recently published national evidence based guidelines thatcover all the clinical aspects of management of IBD6. In parallel a “Service and standards of Care”document has been produced that sets out the requirements that should be in place to deliver a first classservice7. The latter standards are largely consensus based because as for most chronic conditions(including those covered by NICE guidelines), the evidence on care delivery is scanty.The UK IBD Audit seeks to improve the quality and safety of care for IBD patients in hospitalsthroughout the UK by auditing individual patient care, service resources and organisation against nationalstandards. The project is a collaborative working partnership between the Association of Coloproctologyof Great Britain and Ireland, the British Society of Gastroenterology, the National Association for Colitisand Crohn’s Disease and the Royal College of Physicians of London Clinical Effectiveness & EvaluationUnit (CEEu). The project is funded by a grant from the Health Foundation and is a four-year, nation-wide, full cycle comparative audit with initial audit, dissemination, change implementation and re-audit.Specifically, the audit aims to: 1. Assess the current structure and organisation of care for IBD 2. Assess the processes and outcomes of care delivery (inpatient and outpatient) in IBD 3. Enable Trusts to compare their performance against national standards 4. Identify resource and organisational factors that may account for observed variations in care 5. Facilitate, develop and institute an intervention strategy to improve quality of care. 6. Repeat the audit to prove that change has occurred 7. Establish measures that healthcare services can use beyond the study to compare quality of IBD services 8. Develop a sustainability programme to maintain quality of care.This report addresses aims 1, 2, 3 & 4 enabling each site to compare their performance against nationalstatistics.Availability of audit reports in the public domainIndividual hospital site results will not be placed in the public domain as agreed upon registration for thisaudit. Generic National results will be available to the Department of Health in England, the ScottishExecutive Health Department, NHS Wales Department (Welsh Assembly Government) and theDepartment of Health, Social Services and Public Safety in Northern Ireland. More limited summary dataon the first round of audit will be made available to the SHAs and PCTs and to the HealthcareCommission in England. A Concise Report of the National Results from the 1st round will be available inthe public domain via the Clinical Standards section of the Royal College of Physicians external website:www.rcplondon.ac.uk 1 Pearson MG, Littler J, Davies PDO. An analysis of medical workload by speciality and diagnosis in Mersey - evidence of patient to specialist mismatch. J. Roy. Coll. Phys. 1994; 28:230-234 2 Lewison G Gastroenterology in the UK: the burden of disease. PRISM/Wellcome report for the British Society of Gastroenterology. 1997 http://www.bsg.org.uk/pdf_word_docs/burden_disease.pdf 3 Bassi A, Dodd S, Williamson P, Bodger K. Cost of illness of inflammatory bowel disease in the UK: a single centre retrospective study. Gut. 2004;53:1471-8 4 Stenner JMC, White P, Gould SR, Lim AG. Audit of the management of severe ulcerative colitis in a DGH. Gut 2001; 48:A87 5 Card T, Hubbard R, Logan RF. Mortality in inflammatory bowel disease: a population-based cohort study. Gastroenterology. 2003;125:1583-90 6 Agrawal A, Bundred P, Kennedy S, Leiper K, Ellis A, Morris AI, Rhodes JM. Social deprivation and mortality in Crohn’s disease. Presented British Society of Gastroenterology, Glasgow, March 2004. Gut 2004;53:A98 7 Hawthorne AB, Travis SPL and the BSG IBD Clinical Trials Network. Outcome of inpatient management of severe ulcerative colitis: a BSG IBD Clinical Trials Network Survey. Gut 2002; 50:A16 15
  16. 16. UK IBD Audit 2006 ReportMETHODSStandards in the auditThe full proformas of questions are shown in Appendix 2. The questions are largely based on the BSGdocument ‘Guidelines for the management of inflammatory bowel disease in adults’ (Gut. 2004) 1. Thestandards listed against each data item throughout Sections 2- 5 of this report were agreed throughconsensus by the UK IBD Audit Steering Group unless directly stated as otherwise. A full list of thestandards for this report appears as Appendix 6. The set of audit questions were developed by the UKIBD Audit Steering Group and both the questions and data collection method were assessed in extensivepiloting involving data from 23 sites recruited throughout the UK (Appendix 4). These questions, subjectto minor changes that might be considered by the Steering Group as standards change and new areas areconsidered, are to be repeated in Round 2 and will allow an assessment of change in standards over time,a high priority for hospitals.Data collection toolData were collected using the internet. The web tool included context specific online help includingdefinitions and clarifications, internal logical data checks and feedback to enable more complete andaccurate data. Security and confidentiality were maintained through the use of site specific codes. Sitesaccessed the proformas by using unique identifiers and passwords and data could be saved during as wellas at the end of an input session.Definition of a ‘site’Lead clinicians were asked to collect data on the basis of a unified service typically within a singlehospital. Some institutions (7 in total) which run IBD services across two sites with the same staffcompleted the audit as one Trust-wide site.RecruitmentThree individuals from each hospital were approached: a lead Clinician, lead Surgeon and a lead fromwithin their Clinical Audit Department. An overall “audit lead” from each site was then identified,following local discussion. The identified “audit lead” was responsible for the quality of data suppliedby their particular site. Trust Chief Executives were alerted to the study. The target recruitment was setat 80% of Acute Hospitals in the UK that admit patients with IBD – a tough but realistic target for adiscipline without any previous record of national audit. 293 acute hospitals throughout UK were initiallycontacted. Of these 12 said they were not eligible as they did not admit IBD patients acutely. Of theremaining 281 acute hospitals 84% (237) registered to take part, registering as 225 sites (12 of whichwere Trust-wide sites combining 2 hospitals). Country registration of sites was: England 176, NorthernIreland 10, Scotland 22, Wales 15 and the Islands 2 (States of Guernsey HSS & Isle of Mann DHSS).The total number of sites involved in entering data was 200, comprising data from 212 hospitals- a 75%response overall from the 281 applicable acute hospitals initially invited to participate. The data wereentered between 4th September and 31st December 2006.Each participating site was provided with an appropriate login and password and help booklets. Atelephone and email helpdesk was provided by the CEEu, RCP to answer any individual queries.The audit of the site organisation of IBD services was at 1st June 2006. Some questions related todischarges and operations during the 12 month period from 1st June 2005 to 31st May 2006. In total,organisational audit data was received for 181 sites. 16
  17. 17. UK IBD Audit 2006 ReportFor individual patient care, the case-notes were audited of 40 consecutive inpatients (20 Crohn’s Diseaseand 20 Ulcerative Colitis) admitted from 1st June 2006 working backwards as far as 1st June 2004 ifnecessary to identify the 40. This enabled outcome data to be collected for at least 3 months after theadmission before the data entry period commenced in September 2006. Case identification was based ondischarge diagnosis as this defined the standards a clinical team expects to be assessed against. A recentstudy3 showed that a large District General Hospital serving a population of 330,000 admitted 35 patientswith Ulcerative Colitis and 31 patients with Crohn’s Disease over a 6 months period so the targetnumbers were expected to be readily achievable for most NHS Trusts.In total, data were collected for 2767 Ulcerative Colitis patients (from 180 sites), median (IQR) of 19 (11-20) per site, range.1-24In total, data were collected for 2914 Crohn’s Disease patients (from 185 sites), median (IQR) of 19 (12-20) per site, range 2-24.Selection criteria for the patient cohorts (ICD-10 codes)For the Crohn’s Disease and Ulcerative Colitis clinical audits, case identification was based on thedischarge diagnosis using the following relevant ICD codes:- • Crohn’s Disease K50.0 (small intestine), K50.1 (large intestine), K50.8 (other), K50.9 (unspecified). • Ulcerative Colitis K51.0 (enterocolitis), K51.1 (ileocolitis), K51.2 (proctitis), K51.3 (rectosigmoiditis), K51.4 (pseudopolyposis of colon), K51.5 (mucosal proctocolitis), K51.8 (other), K51.9 (unspecified)A patient was to be included in the clinical audit only once, this being for the most recent admission priorto 1st June 2006. For the Organisational audit multiple admissions were to be counted for discharges andoperations during the year prior to 1st June 2006.Patients were to be included in the audit if the primary reason for admission was because of IBD orsymptoms that were later diagnosed as IBD and excluded if IBD was not indicated as the main reason e.g.a person with known IBD admitted because of a myocardial infarction.Day cases were to be excluded, such as for endoscopy or drug infusions or if a patient was admitted for aday but stayed overnight and was discharged the following day. Patients with a diagnosis ofindeterminate Colitis were also excluded as were patients under the age of 16.Data reliabilityPilot audit sites were asked to enter 20 cases (10 UC and 10 Crohn’s) and re-audit 5 cases using adifferent auditor. For Ulcerative Colitis, duplicate data was available for 93 patients (from 22 sites);Crohn’s Disease 91 patients (from 22 sites). These limited numbers for analysis had scope only forassessing the grey areas of judgement relating to the more common events. However, the levels ofagreement (where assessable) were generally good with kappa agreement statistics of 0.60 and higherdominating the results. With Ulcerative Colitis the median (IQR) kappa value was 0.87 (0.76-0.93) n=61data items, for Crohn’s Disease 0.80 (0.66-0.88), n=85 inpatient items and 0.69 (0.50-0.84) n=19outpatient items. Kappa levels tended to be higher for patient characteristics and medication details thanfor other information which required a greater degree of scrutiny of case-notes. 17
  18. 18. UK IBD Audit 2006 ReportPresentation of resultsWherever possible the audit question numbers have been added within tables of results to facilitatereference to the actual questions in the audit proformas in Appendix 2. • Section 1 provides a breakdown of Key National Results by country. • Section 2 gives the national summary results for the organisational audit for all of the sites participating in this audit. • Section 3 gives the national summary results for the audit of Ulcerative Colitis inpatients. • Sections 4 & 5 give the national summary results for the audit of Crohn’s Disease inpatients and outpatients.National results are presented as percentages for categorical data and as median and inter-quartile range(IQR) for numerical data. Site variation is also summarized by the median and IQR and in graphical formby histogram plots. 18
  19. 19. UK IBD Audit 2006 ReportRESULTSSection 1. Key National Results for England, Northern Ireland, Scotland and WalesThe sites that registered were, by country: England 176, Northern Ireland 10, Scotland 22,Wales 15The number of sites entering data into the audit (Organisational and/or Ulcerative Colitis and/or Crohn’sDisease) were: England 159, Northern Ireland 10, Scotland 14, and Wales 15.Organisation and Structure:The number of sites entering data into the organisational audit were: England 145, Northern Ireland 10,Scotland 10, and Wales 14. England N. Ireland Scotland Wales (145) (10) (10) (14) 2.1 Discharges 1/6/05 -31/5/06 with primary Median: 55, Median: 39, Median: 62, Median: 33, diagnosis of Ulcerative Colitis n=133 n=10 n=9 n=13 2.1 Discharges 1/6/05 -31/5/06 with primary Median: 65, Median: 47, Median: 78, Median: 26, diagnosis of Crohn’s Disease n=133 n=10 n=9 n=13 2.2 Discharges 1/6/05 -31/5/06 having had operation where primary indication was Ulcerative Median: 14, Median: 11, Median: 10, Median: 7, Colitis n=126 n=10 n=9 n=12 2.2 Discharges 1/6/05 -31/5/06 having had operation where primary indication was Crohn’s Median: 17, Median: 20, Median: 17, Median: 9, Disease n=126 n=10 n=9 n=12 2.3 On site ileo-anal pouch surgery ? 79% (114/144) 30% (3) 50% (5) 57% (8) If, yes, how many between 1/6/05 and 31/5/06 Median: 4, Median: 7, Median: 2, Median: 3, n=109 n=2 n=5 n=6 3.1 Dedicated gastroenterology ward? 74% (107) 30% (3) 60% (6) 43% (6) If yes, how many beds per lavatory on the ward Median: 4.6, Median: 5.0, Median: 2.6, Median: 4.0, n=104 n=3 n=6 n=5 3.4 IBD Nurse Specialists on site? 61% (88/144) 10% (1) 60% (6) 36% (5) 5.2 Do timetabled meetings take place between the following specialties: Gastroenterologists & Colorectal Surgeons 82% (119) 30% (3) 30% (3) 64% (9) Gastroenterologists & Radiologists 90% (131) 70% (7) 50% (5) 64% (9) Colorectal Surgeons & Radiologists 90% (130/144) 50% (5) 70% (7) 64% (9) Median: 2 Median: 0.5 Median: 5 Median: 2 6.4 How many dietetic sessions per week are dedicated to GI disorders? %None: 24% %None: 44% %None: 22% %None: 36% (33/138) (4/9) (2/9) (5/14) 10.4 Existing pathways for direct access to psychological support 21% (31) 30% (3) 20% (2) 0% (0) 12.1 Does your hospital offer open forums or meetings for patients with IBD? 34% (50) 10% (1) 0% (0) 21% (3) 19
  20. 20. UK IBD Audit 2006 Report Ulcerative Colitis Inpatients: The number of sites entering data into the Ulcerative Colitis audit were: England 149, Northern Ireland 10, Scotland 12, and Wales 13. England N. Ireland Scotland Wales (2302) (158) (134) (167)1.1.9 Was the patient transferred to a specialist gastroenterology ward? (NON-ELECTIVES) a) Medical, surgical or joint 72% (1412/1964) 44% (62/141) 54% (60/112) 63% (93/147) d) Not transferred 28% (552/1964) 56% (79/141) 46% (52/112) 37% (54/147)1.3.1 Did the patient die during admission 1.8% (42/2302) 0.6% (1/158) 0% (0/134) 1.2% (2/167)(ALL PATIENTS)2.2.5 Stool sample sent for Standard Stool 60% (1172/1962) 57% (80/141) 46% (51/112) 57% (84/147)Culture (NON-ELECTIVES)2.2.6 Stool sample sent for CDT? 47% (922/1962) 47% (66/141) 36% (40/112) 50% (74/147)(NON-ELECTIVES)2.3.3 Biopsies taken for histology at 78% (775/995) 80% (56/70) 77% (50/65) 70% (57/81)endoscopy (NON-ELECTIVES)Days after admission that histology reports Median: 9 days Median: 6 days Median: 7 days Median: 9 daysapproved by histology:3.1.1 Patient given Prophylactic heparin 61% (1415/2302) 44% (69/158) 52% (70/134) 58% (97/167)(ALL PATIENTS)3.1.9 (high CRP) and 4.1.4 (high stool frequency) after 3 days for high dose steroids % with surgery 41% (73/178) 40% (4/10) 38% (3/8) 64% (7/11) % with ciclosporin 27% (48/178) 10% (1/10) 25% (2/8) 27% (3/11) % with anti-TNF therapy 4% (7/178) 10% (1/10) 13% (1/8) 0% (0/11)5.1.2 Who made the decision to operate? (ELECTIVES with surgery) a) Consultant Colorectal Surgeon 80% (260) 65% (11) 91% (20) 65% (13) b) Consultant GI Surgeon (non-colorectal) 0.6% (2) - - - - - - c) Consultant General Surgeon 0.6% (2) 12% (2) - - 5% (1) d) Other Consultant Surgeon 0.3% (1) - - - - - - e) Specialist Registrar 3% (9) 6% (1) - - 5% (1) f) *Other (please specify) 3% (10) - - - - 5% (1) Not documented 16% (54) 18% (3) 9% (2) 20% (4)5.1.2 Who made the decision to operate? (NON-ELECTIVES with surgery) a) Consultant Colorectal Surgeon 84% (207) 80% (16) 73% (16) 69% (20) b) Consultant GI Surgeon (non-colorectal) 4% (10) 10% (2) 5% (1) 3% (1) c) Consultant General Surgeon 4% (11) 10% (2) 14% (3) 14% (4) d) Other Consultant Surgeon 0.8% (2) - - - - - - e) Specialist Registrar 4% (9) - - - - - - f) *Other (please specify) 0.4% (1) - - - - 3% (1) Not documented 3% (7) - - 9% (2) 10% (3) 20
  21. 21. UK IBD Audit 2006 ReportCrohn’s Disease (inpatients & outpatients):The number of sites entering data into the Crohn’s Disease audit were: England 149, Northern Ireland 10,Scotland 12, and Wales 13. England N. Ireland Scotland Wales (2384) (159) (169) (194)1.6.1 Smoking status (ALL PATIENTS) a) Current smoker 30% (715) 38% (61) 38% (65) 35% (68) b) Lifelong non-smoker/ ex-smoker 55% (1307) 47% (74) 52% (88) 52% (101) c) Not documented 15% (362) 15% (24) 9% (16) 13% (25)2.2.1 Stool sample sent for Standard StoolCulture (NON-ELECTIVES with 48% (474/995) 49% (35/71) 49% (45/92) 47% (39/83)diarrhoea (2.1.1))2.2.2 Stool sample sent for CDT (NON- 36% (355/992) 41% (29/71) 35% (32/92) 39% (33/84)ELECTIVES with diarrhoea (2.1.1))2.5.1 Patient weight measured during 52% (990/1907) 53% (70/133) 51% (76/148) 53% (86/162)admission (NON-ELECTIVES) 31% (307/990) 34% (24/70) 34% (26/76) 22% (19/86) BMI measured2.5.2 Did a dietitian visit the patient? 36% (696/1907) 38% (50/133) 41% (61/148) 39% (63/162)2.6.1 Patient given Prophylactic heparin 63% (1506) 57% (90) 52% (88) 66% (128)3.3.2 Evidence of chest x-ray performed in3 months before anti-TNF- therapy? 72% (68/95) 78% (7/9) 50% (5/10) 67% (4/6)(NON-ELECTIVES with antiTNF therapy(3.3.1))4.1.3 Which Surgeon made the decision to operate? ( ELECTIVES with surgery) a) Consultant Colorectal Surgeon 78% (366) 60% (15) 48% (10) 65% (20) b) Consultant GI Surgeon (non-colorectal) 2% (11) - - 10% (2) 3% (1) c) Consultant General Surgeon 2% (11) 8% (2) 14% (3) 6% (2) d) Other Consultant Surgeon - - - - - - - - e) Specialist Registrar 2% (10) - - - - 3% (1) f) Other (please specify)* 2% (9) - - - - 3% (1) Not documented 13% (63) 32% (8) 29% (6) 19% (6)4.1.3 Which Surgeon made the decision to operate? (NON-ELECTIVES with surgery) a) Consultant Colorectal Surgeon 68% (297) 50% (10) 71% (25) 66% (35) b) Consultant GI Surgeon (non-colorectal) 7% (31) 20% (4) 6% (2) 6% (3) c) Consultant General Surgeon 8% (36) 20% (4) 17% (6) 11% (6) d) Other Consultant Surgeon 1% (5) - - - - 2% (1) e) Specialist Registrar 10% (44) - - 3% (1) 4% (2) f) Other (please specify)* 2% (9) 5% (1) - - 6% (3) Not documented 3% (13) 5% (1) 3% (1) 6% (3)4.1.9i Surgery done laparoscopically/laparoscopically-assisted? 14% (62/450) 10% (2/21) 5% (1/21) 0% (0/29)(ELECTIVES with surgery)4.1.9i Surgery done laparoscopically/laparoscopically-assisted? 8% (32/409) 31% (5/16) 3% (1/35) 2% (1/43)(NON-ELECTIVES with surgery)4.3.1 Patient prescribed any of the following drugs on discharge (ELECTIVES with segmental or extended colectomy, subtotalcolectomy, Ileal / Jejunal resection, or Ileocolonic resection surgery) a) Azathioprine 21% (69/334) 29% (4/14) 14% (2/14) 21% (5/24) b) Mercaptopurine 2% (6/334) - (0/14) 7% (1/14) - (0/24) c) Metronidazole 7% (25/334) - (0/14) - (0/14) 4% (1/24) d) 5-ASA 35% (117/334) 86% (12/14) 21% (3/14) 21% (5/24) e) Methotrexate 1% (5/334) - (0/14) - (0/14) 4% (1/24) f) None 46% (155/334) 14% (2/14) 57% (8/14) 54% (13/24) 21
  22. 22. UK IBD Audit 2006 Report England N. Ireland Scotland Wales (2384) (159) (169) (194)4.3.1 Patient prescribed any of the following drugs on discharge (NON-ELECTIVES with segmentmental extended colectomy,subtotal colectoy, Ileal / Jejunal resection, or Ileocolonic resection surgery) a) Azathioprine 15% (50/325) 14% (2/14) 21% (6/29) 15% (6/41) b) Mercaptopurine 2% (5/325) - (0/14) - (0/29) - (0/41) c) Metronidazole 8% (25/325) - (0/14) - (0/29) 2% (1/41) d) 5-ASA 27% (87/325) 50% (7/14) 28% (8/29) 22% (9/41) e) Methotrexate 2% (6/335) - (0/14) - (0/29) 2% (1/41) f) None 56% (181/325) 50% (7/14) 59% (17/29) 63% (26/41)6.4.3 How often was WBC monitoring performed? (LAST OPD before admission (6.1.1), if WBC routinely measured (6.4.2) andon Azathioprine, mercaptopurine or Methotrexate in 12 months before admission (6.4.1)) At least once a month 38% (238/625) 41% (11/27) 42% (19/45) 24% (11/46) Every 2-3 months 53% (33/625) 44% (12/27) 44% (20/45) 63% (29/46) Less frequently 1% (8/625) - (0/27) 2% (1/45) 2% (1/46) Not documented/unable to interpret 8% (48/625) 15% (4/27) 11% (5/45) 11% (5/46)6.5.1 Patient taking oral corticosteroids forCrohn’s Disease in 12 months before 56% (866/1544) 54% (49/91) 53% (54/102) 62% (77/125)admission? ( LAST OPD (6.1.1))6.5.2 Any point at which patient takingoral corticosteroids continuously for more 45% (390/866) 47% (23/49) 46% (25/54) 60% (46/77)than three months (LAST OPD (6.1.1))6.5.3 Bone protection agents prescribedalongside corticosteroids? (LAST OPD 46% (398/866) 49% (24/49) 26% (14/54) 51% (39/77)(6.1.1))6.5.4 Bone densitometry measured within12 months of initiation of corticosteroid 18% (160/866) 8% (4/49) 17% (9/54) 14% (11/77)therapy? (LAST OPD (6.1.1))6.5.3 Bone protection agents prescribedalongside corticosteroids for those taking 55% (214/390) 61% (14/23) 40% (10/25) 59% (27/46)oral corticosteroids continuously for morethan 3 months (6.5.2). (LAST OPD (6.1.1)) 22
  23. 23. UK IBD Audit 2006 ReportSection 2. Organisation & Structure of IBD services as at 1st June 2006Auditor Discipline National (181 sites) Consultant 78% (142) Other medical staff 15% (28) Nurse 22% (39) Audit staff 13% (24) Other* 6% (11)* Other included SPR (3), Dietician (2), medical student (2), database manager, general manager, information staff, medicalsecretary.General Hospital DemographicsStandard:Hospitals where surgery is performed for IBD should have ITU beds with 24 hr care byanaesthetists/intensivists on-site. National (181 sites)1.1 How many beds does your hospital have in total? Median (IQR) 540 (396-798), n=1771.2 Does your hospital have either of the following? Acute medicine unit 98% (178) Acute surgical unit 77% (138/180)1.3 Is there an Intensive Therapy Unit (ITU) on site? % YES 71% (128) If yes, how many beds Median (IQR) 7 (6-10), n=1261.4 Is there a High Dependency Unit (HDU) on site? % YES 66% (120) If yes, is it: a) Medical 8% (9/118) b) Surgical 14% (16/118) c) Mixed 79% (93/118) If yes, how many beds Median (IQR) 6 (4-9), n=1191.5 Is there a combined Intensive Therapy (ITU) & % YES 25% (45)High Dependency (HDU) Unit on site? If yes, is it: a) Medical 2% (1) b) Surgical 0% (0) c) Mixed 98% (44) If yes, how many beds Median (IQR) 10 (8-16), n=45There were 4 sites that did not have ITU nor HDU beds on site – these were the 4 smallest hospitals in theaudit. 23
  24. 24. UK IBD Audit 2006 ReportInpatient ActivityStandard:2.3 Patients undergoing surgery for ulcerative colitis should have the opportunity to have ileo-anal pouchsurgery either locally (BSG Guidelines), if available, or at a regional centre. National (181 sites)2.1 How many patients were discharged between 1st June Median (IQR) 50 (25-105), n=1672005 and 31st May 2006 with a primary diagnosis of Range 1-481Ulcerative Colitis2.1 How many patients were discharged between 1st June Median (IQR) 61 (30-112), n=1672005 and 31st May 2006 with a primary diagnosis of Range 2-609Crohn’s Disease2.2 How many patients were discharged between 1st June2005 and 31st May 2006 having had an operation where Median (IQR) 11 (5-30), n=159the primary indication was Ulcerative Colitis2.2 How many patients were discharged between 1st June2005 and 31st May 2006 having had an operation where Median (IQR) 16 (9-40), n=159the primary indication was Crohns Disease2.3 Do surgeons perform ileo-anal pouch surgery on site? % YES 72% (130/180)If yes, how many ileo-anal pouch operations were Median (IQR) 4 (2-7), n=122performed between 1st June 2005 and 31st May 2006?Gastroenterology ServicesStandards:3.1 Specialty triage of emergency admitted IBD patients to appropriate medical or surgical gastroenterology.3.2 No more than 3 patients per lavatory.3.3 At least 2 WTE Medical Gastroenterologists.3.4 & 3.5 At least 1 IBD specialist nurse with at least 5 sessions dedicated to IBD. National (181 sites)3.1 Is there a dedicated Gastroenterology ward? % YES 67% (122)If yes, how many beds per lavatory on the ward Median (IQR) 4.5 (3.0-6.0), n=118 3 (2-4), range 1-9,3.2 How many WTE Gastroenterologists are there on site? Median (IQR) n=1813.3 How many Gastroenterology staff of the following grades are there on site? 2 (1-2), n=180, i. Specialist Registrar (SpR) Median (IQR) 12% (21) NONE 0 (0-1), n=179 ii. Associate Specialist Median (IQR) 69% (124) NONE 1 (0-1), n=1803.4 How many IBD Nurse Specialists are there on site? Median (IQR) 44% (80) NONE3.5 How many sessions of Specialist Nurse time are 6 (4-10), n=90/100 Median (IQR)dedicated to IBD care per week? Range 1-50In only 25% (30/118) of sites with a dedicated gastroenterology ward was there 3.0 or fewer beds per lavatory. In 26%(31/118) there was 6.0 or more beds per lavatory. The histogram of beds per lavatory is as follows: 24
  25. 25. UK IBD Audit 2006 ReportSite variation histogram: Beds per lavatory on the ward.Note that two outliers have been excluded from the histogram 25 20 15 Sites 10 5 0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Gastroenterology Beds Per LavatorySite variation histogram: Number of IBD specialist nurse sessions.Note that one outlier has been excluded from the histogram 90 80 70 60 Sites 50 40 30 20 10 0 0 5 10 15 20 25 Sessions of Specialist Nurse time dedicated to IBD care per week 25
  26. 26. UK IBD Audit 2006 ReportColorectal ServicesStandards:4.1 At least 2 FTE Colorectal surgeons.4.3 & 4.4 At least 1 stoma-care nurse specialist with at least 5 sessions dedicated to stoma care. National (181 sites)4.1 How many WTE specialist Colorectal Surgeons are 3 (2-4), n=178 Median (IQR)there on site? 5% (9) NONE4.2 How many Colorectal staff of the following grades are there on site? 2 (1-2), n=177 i. Specialist Registrar (SpR) Median (IQR) 12% (22) NONE 0 (0-1), n=176 ii. Associate Specialist Median (IQR) 61% (107) NONE 2 (1-3), n=1774.3 How many Stoma Nurses are there on site? Median (IQR) 4% (8) NONE4.4 How many sessions of Stoma Nurse time are 10 (7-20), n=132/169 Median (IQR)dedicated to stoma care per week? Range 1-85Multi-Disciplinary WorkingStandards:5.1 Sites should have a searchable data-base to allow adequate audit.5.2 A weekly multi-disciplinary meeting should take place between gastroenterologists, colorectal surgeonsand radiologists. There should be regular histopathology conferences (at least 1 per month).5.3 & 5.4 Each hospital should have a radiologist and pathologist with a special interest in gastroenterology. National (181 sites)5.1 Is there a searchable database of IBD patients on site? % YES 34% (62/180)5.2 Do timetabled meetings take place between the following specialties: i. Gastroenterologists and Colorectal Surgeons % YES 74% (134) ii. Gastroenterologists and Pathologists % YES 78% (142) iii. Gastroenterologists and Radiologists % YES 85% (153) iv. Colorectal Surgeons and Pathologists % YES 77% (139/180) v. Colorectal Surgeons and Radiologists % YES 84% (152/180)5.3 Is there a specialist GI Pathologist? % YES 67% (122)5.4 Is there a specialist GI Radiologist? % YES 71% (129) 26
  27. 27. UK IBD Audit 2006 ReportDietetics and Nutritional ServicesStandards:6.1-6.3 Each site should have a multidisciplinary nutrition team. This team should conduct ward rounds atleast twice a week.6.4 At least 5 dietetic sessions per week should be dedicated to gastroenterological diseases ( includesinpatients and outpatients). National (181 sites)6.1 Is there a hospital nutrition team? % YES 62% (112)6.2 Is it a multi-disciplinary team? % YES 94% (105/112)6.3 Does the team go on ward rounds? % YES 79% (88/112) If yes, how frequently? %Daily 32% (28/88)6.4 How many dietetic sessions per week are dedicated to GI Median (IQR) 2 (0-5), n=171disorders?Site variation histogram: Number of sessions of dietetic support 60 50 40 Sites 30 20 10 0 0 5 10 15 20 25 Dietetic sessions per week dedicated to GI disorders 27
  28. 28. UK IBD Audit 2006 ReportOutpatient ServicesStandards:7.1-7.3 A clear process for telephone access for ill patients should be established that allows review withinone week. Written information for patients with IBD should be readily available in clinic areas (BSGguidelines).7.4 Joint or parallel clinics should exist to discuss and refer patients between medical and surgical teams. National (181 sites)7.1 Is there written information for patients with IBD on whom % YES 64% (114/179)to contact in the event of a relapse?7.2 In general, how soon could a relapsed patient expect to be seen in clinic? a) Less than 7 days % YES 63% (113/179) b) Between 7-14 days % YES 32% (58/179) c) Other (please specify)* % YES 4% (8/179)7.3 Do patients have access to an IBD specialist by any of the following methods (tick all thatapply) a) Telephone % YES 76% (136/180) b) Drop-in clinic % YES 14% (26/180) c) Email % YES 28% (50/180) d) None of these % YES 23% (41/180)7.4 Are there any joint or parallel clinics run between Gastroenterologists and Surgeons? a) Joint % YES 13% (24/180) b) Parallel % YES 37% (67/180) c) Neither % YES 53% (96/180)* Other comprised 21 days (2), 3-4 weeks (2), 4-8 weeks, 7-28 days, very variable, not applicable.Patient InformationStandard:8.1 Written information on IBD should be provided to each patient with IBD (BSG Guidelines). National (181 sites)8.1 Are patients provided with written information about IBD? % YES 95% (172/181)i. If yes, is the information produced by: a) NACC % YES 88% (160) b) Pharmaceutical % YES 53% (95) c) Locally written % YES 45% (82) d) Drug specific % YES 51% (92) e) Other (please specify)* % YES 8% (15)* Other comprised: 7 CORE, 4 Digestive Disease Foundation, 2 Ileostomy Association, 1 patient.co.uk website and 1 BritishDietary Disorders Leaflet 28
  29. 29. UK IBD Audit 2006 ReportMonitoring of established immunosuppresive therapyStandard:9.1 There should be a written policy for the mechanism of monitoring immunosuppressive therapy (NationalPatient Safety Agency) National (181 sites)9.1 How is established immunosuppresive therapy monitored? (Please tick all that apply) a) By the GP % YES 24% (43) b) A dedicated monitoring service % YES 20% (36) c) During clinic visits % YES 49% (88) d) A combination of primary and secondary care monitoring % YES 72% (131)IBD Support ServicesStandard:10.1 There should be regular (usually 1 or 2 per year) transition clinics involving paediatricians and adultgastroenterologists for hand over of patients to adult services. These can be done on a regional basis. National (181 sites)10.1 Is there a paediatric to adult handover clinic for young patients with IBD? % YES 23% (42/180)10.2 Is a registered counsellor available to patients as part of your IBD Service? % YES 5% (9/179)10.3 Are there any psychologists attached to the Gastroenterology service? % YES 7% (12/179) If yes, how many sessions per month are dedicated to Gastroenterology service? Median (IQR) 4, (1-7), n=1210.4 Do pathways exist for direct access to psychological support? % YES 21% (37/179)10.5 Is there an acute pain management team on site? % YES 92% (166)Management of Ulcerative ColitisStandard:Written Trust guidelines should exist for the management of acute or severe colitis. National (181 sites)11.1 Do written trust guidelines exist for the management of % YES 47% (84/180)acute or severe colitis? 29
  30. 30. UK IBD Audit 2006 ReportInteractions between your hospital and patients and patient groupsStandard:12.1 There should be regular meetings (at least once a year and usually on a regional basis) between groupsof patients with IBD (and their relatives or carers) and hospital staff, this should involve medical, surgicaland nursing staff. National (181 sites)12.1 Does your hospital offer open forums or meetings for % YES 30% (54)patients with IBD?i. If yes, how often do these take place? a) Less than 4 monthly % YES 13% (7/53) b) Every 4-8 months % YES 36% (19/53) c) Every 8-12 months % YES 43% (23/53) d) Other (please specify)* % YES 8% (4/53)ii. If yes (n=54), which staff attend these meetings? a) Medical % YES 89% (48) b) Surgical % YES 33% (18) c) Nursing % YES 80% (43)12.2 Are any of the following activities or systems in place to involve patients in giving their viewson the development of your IBD services? (Please tick all that apply) a) Regular patient surveys % YES 27% (48) b) Individual patient representatives % YES 7% (13) c) Patient panel meetings % YES 7% (12) d) None % YES 65% (118)* Other comprised: occasional, invitation by NACC, patient panels every 6 months, first forum June 06 then 6 monthly. 30
  31. 31. UK IBD Audit 2006 ReportSection 3. Clinical Audit Ulcerative Colitis (inpatient)In total, data were collected for 2767 Ulcerative Colitis patients (from 185 sites), median (IQR) of 19 (11-20) per site, range.1-24. Your site - cases.Auditor Discipline: National (2767) % NConsultant 23 632Other medical staff 42 1152Nurse 28 778Manager 0.5 15Other (please specify)* 11 293* Other included Clinical audit/effectiveness (158), medical student (51), SHO/SPR (36), medical secretary (21), specialistnurse (10),Patient Demographics National (2767) Median IQRPatient age* (years) 43 30-61Derived from year of birth and year of admission National (2767)Gender % N Male 53 1458 Female 47 1309When were patients admitted?79% (2194/2767) of cases audited were admitted in the 12 month period prior to 1st June 2006.95% (2638/2767) of cases audited were admitted in the 24 month period prior to 1st June 2006.Admission 2004 2005 2006January 4 35 239February 4 34 230March 3 45 263April 6 63 255May 6 83 237June 17 112 33July 19 117 16August 34 106 16September 23 128 10October 26 162 9November 39 171 2December 26 174 1There were also 11 cases from 2003, 2 from 2002 and 6 from 2001 included in the audit. 31
  32. 32. UK IBD Audit 2006 ReportAdmissionStandards:1.1.5 Patients should be transferred to the care of a medical gastroenterologist or colorectal surgeon within24 hours of admission.1.1.6 Patients should be seen by a consultant gastroenterologist or colorectal surgeon within 3 days ofadmission.1.1.8 Patients should be seen by an IBD specialist nurse during admission.1.1.9 Patients should be transferred to a specialist gastroenterology ward. National (2767) % N1.1.2 What was the source of admission to hospital? a) General Practitioner (GP) 31% 845 b) Accident and Emergency (A&E) 27% 743 c) Outpatients Department (OPD) 37% 1019 d) Other hospital 1% 40 e) Not documented 4% 1201.1.3 What was the duration of active colitis (new or relapse) precipitating this admission? a) Less than two weeks 34% 943 b) Two to three weeks 18% 485 c) Four to eight weeks 18% 496 d) More than eight weeks 20% 547 e) Not documented 11% 2961.1.4 What was the primary reason for admission? a) Emergency admission for active Ulcerative Colitis 75% 2074 b) Planned admission for active Ulcerative Colitis 11% 296 c) Elective admission for surgery 14% 397 The rest of this table excludes 397 Elective admission, total n=23701.1.5 Which specialty was responsible for the patients initial care 24 hours after admission? a) Acute Medicine 31% 739 b) Gastroenterology 34% 808 c) Colorectal Surgery 10% 238 d) Geriatrics 1% 28 e) General Medicine 10% 234 f) General Surgery 13% 299 g) Other (please specify)* 1% 241.1.6 What date was the person first seen by a Consultant Gastroenterologist? Not Seen 20% 469 Not required 27% 128/469 Median (IQR) N If seen 1 (1-3) 19011.1.6 What date was the person first seen by a Consultant Colorectal Surgeon? Not Seen 65% 1545 Not required 54% 842/1545 Median (IQR) N If seen 2 (1-7) 8251.1.8 Was patient visited by an IBD Nurse/GI Nurse specialist during admission? YES 22% 533 IN UNITS with a IBD Nurse (Organisational audit)** 36% 450/12431.1.9 Was the patient transferred to a specialist gastroenterology ward? a) Medical 51% 1215 b) Joint 5% 127 c) Surgical 12% 285 d) Not transferred 31% 743* Other included paediatrics (11), Obs/Gynae (4), A&E, acute general surgery, HIV/GUM, infectious diseases, ITU, Renal,Rheumatology.** Note that the organisational audit asked about IBD services as at 1st June 2006, whereas almost all of the clinical auditcases were prior to 1st June 2006. , 32
  33. 33. UK IBD Audit 2006 Report10% (238/2370) were not seen by either a consultant gastroenterologist or a consultant colorectal surgeon.3% (26/808) of those under the gastroenterology specialty after 24 hours were not seen by a gastroenterologist.13% (31/238) of those under the colorectal surgery specialty after 24 hours were not seen by a colorectal surgeon.Comorbidity National (2767) % N1.2.1 Does the patient have any significant co-morbid diseases? (please tick all that apply) a) Heart Disease 10 264 b) Peripheral Vascular Disease 1 30 c) Respiratory 7 193 d) Renal Failure 0.8 23 e) Diabetes 6 168 f) Stroke 2 59 g) Liver Disease 1 36 h) Active cancer 0.8 22 i) None 77 2136 Not Known 1 30Inpatient Mortality National (2767) % N1.3.1 Did the patient die during admission? YES* 1.6% 45* Median (IQR) N Date of death: days from admission 24 (18-44) 45* 7 sites with two deaths, 31 with one death.25 (56%) of deaths were directly related to UC including 15 which occurred in patients who had surgery. Two deathswere related to colon cancer. For the remainder, the primary cause of death was: 10 respiratory disease, 5 heart disease, 2multi-organ failure, 1 cerebrovascular disease, 1 renal failure, 1 thromboembolic disease.19 (42%) had no co-morbiditiy. 36 patients had co-morbidity (n=13 with more than 1): 18 had heart disease, 8 respiratorydisease, 7 diabetes, 2 renal failure, 3 stroke and 1 active cancer. 15/45 had no antithrombotic prophylaxis (18 no prophylacticheparin, 27 no anti-thrombotic stockings). Three patients died of thrombotic complications (2 pulmonary embolism and oneSMA thrombosis)- only one was not on prophylactic heparin.Mortality after Discharge National (2767) % N1.3.2 Did the patient die after discharge? YES* 1.7% 47* Median (IQR) Date of death: days from admission 80 (51-160) 43* one site reported 3 deaths, 5 sites two deaths, 34 sites one death8 deaths were related to UC comprising 4 colorectal cancer, 3 septicaemia and 1 perforated colon. The remainder comprised:12 respiratory disease, 2 heart disease, 4 cancer, 14 not known, 2 strokes, 1 each of peripheral vascular disease, septicaemia ofunknown cause, small intestinal perforation, multiorgan failure, old age. There were no recorded deaths due tothromboembolic disease. 33
  34. 34. UK IBD Audit 2006 ReportLength of stay (Discharged) 250Median LOS: 8 days 200IQR: 5-13 days.0-1 days: 3% (74) 150 Cases0-2 days: 8% (224)3-6 days: 26% (703) 100 50Your site: median - days. 0 0 10 20 30 40 50 60 70 80 90 100 LOS (days)Assessment: Patient History National (2767) % N2.1.1 Did the patient have a pre-admission diagnosis of Ulcerative Colitis? YES 83% 23032.1.2 Has the patient had previous admissions with Ulcerative Colitis? YES 51% 1186/2303 If yes, how many times in the two years prior to Median (IQR) N this admission? 1 (1-2) 1186 34

×