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  • 1. UK IBD Audit – Model Action Plan for IBD Services This is a new venture and we hope that you can interact with the UK IBD Audit to improve the model action plan. We encourage you to contribute towards the development of the document and to criticise the suggestions contained within it. The plan is primarily designed as a resource template which you could use in conjunction with the data that you received in your site report from the 1st round of the UK IBD Audit to plan improvements within your own service. The plan is by no means considered to be a definitive guide on how to develop an IBD service but rather it suggests possible actions against the key messages highlighted in the Executive Summary of the 1st round of the UK IBD Audit National Report . We would be very grateful if you could send us a copy of any of your own examples of care pathways, patient information sheets, drug charts etc that you would be happy for us to post onto the IBD Audit website so that they would be available for reference and possibly adaptation by the wider UK IBD community. These examples can be completely anonymised or fully acknowledged depending on your wishes. Examples can be sent to: ibd.audit@rcplondon.ac.ukFor any further information on the UK IBD Audit please contact Calvin Down on 020 7935 1174 ext 566 or at: calvin.down@rcplondon.ac.ukThe action plan and supporting documents will be regularly updated via the action plan section on the RCP UK IBD Audit web page: http:// www.rcplondon.ac.uk/college/ceeu/ceeu_uk_ibd_audit.htm How to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 1 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 2. Audit Indicator Suggested choice of action Suggested people to lead or involve • Multidisciplinary team working functions Establishing a Multidisciplinary Team (MDT) Consultant well with timetabled meetings between - Build on to existing MDT practices (cancer or ward based MDTs Gastroenterologists & gastroenterologists and surgeons in 74% of - Personnel can include gastroenterologist/gastroenterology unit Colorectal Surgeons sites. Joint or parallel medical-surgical staff/Ward nurse/IBD nurse/social co-ordinated by Clinical Nurse clinics occur in only 47%. Comment: IBD worker/surgeon/pharmacist/dietitian/stoma nurse Specialist or MDT co- MDT meetings should occur regularly at all - If you do not have a multi-disciplinary team then first steps may ordinator sites. be as simple as a Gastroenterologist and Surgeon having a one-off meeting to discuss individual patients. Timeframe - The co-ordinator of MDT can be middle grade junior doctor (registrar)/senior medical or surgical staff, clinical nurse specialist Initial steps to discuss the or a MDT co-ordinator format can be taken immediately. 3-6 months to - Ideally meetings should be a Gastroenterologist, Surgeon, confirm the venue and alter Radiologist and IBD Nurse Specialist (if you have one). Meetings timetables if needed. need not be exclusively be IBD but involve discussion of other patients - We would advise that it is more worthwhile to discuss ‘difficult’ cases rather than all cases of IBD. MDT meetings tend to work better on a weekly basis. Establishing a joint/parallel medical-surgical clinic - Parallel clinics are more time efficient than joint medical-surgical clinics, whereby patients are reviewed by medical or surgical team on an ‘ad hoc’ basis from one speciality to the other - It is recognised that many sites do not have facilities to offer all services (for example pouch surgery). Team needs to have a recognised link with a centre which provides this serviceHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 2 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 3. - If not offering pouch surgery, form a link with another centre - Get this pathway agreed by PCT as part of the IBD service - If no joint gastro/surgical get one person on each team formally identified as the link person - Build on existing practice however it works - Change clinics to be parallel if possible - Run a combined clinic occasionally, use direct referral if more urgent. Having a whole or part clinic occasionally as a joint clinic may be a start. - Building relationships (study day together?) - Develop a combined colonoscopy list and review meetings for endoscopy service screening - Service delivery/clinical governance meetings-use these to review IBD Establishing better working relationships across professions who are not working as a team - Look to build consensus around particular problems - Choose simple guidelines and audit-review after 6 months - Set a task you can work on together (e.g. AZA monitoring) - Get a local audit done of some aspect of care (surgical registrars have to do one) - Participate in a trial that requires joint medical/surgical activity.How to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 3 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 4. Audit Indicator Suggested choice of action Suggested people to lead or involve • Hospitals vary considerably in their yearly This is a sensitive issue and this plan of smaller hospitals interacting with Contact Gastroenterology inpatient activity in IBD; median larger centres is only suggestive. Problems can occur at smaller hospitals departments at larger centres if (Interquartile range [IQR]) 50 (25-105) particularly when there is study or annual leave. We suggest that if you felt necessary to do so. range 1-481 for Ulcerative Colitis and 61 have insufficient cover then consider cross-cover from colleagues from (30-111) range 2-609 for Crohn’s Disease. another local hospital. Timeframe 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 Below are suggestions which may be of practical use in making a IBD clinician and line manager specialist(s). Amongst those with specialist business case for an IBD Clinical Nurse Specialist. Remember that often Health technology agency nurses, the median number of sessions best way to gain funding is to have a job plan which involves another WKCTA dedicated to IBD care is 6 per week. aspect or care- e.g. endoscopy. R+D department Comment: IBD clinical nurse specialist(s) Medical director service needs to be expanded to include all An example of a job description for an IBD Specialist Nurse developed Appropriate PCT sites caring for patients with IBD. by Addenbrooke’s hospital can be seen in Appendix 1. This example has Commissioner been kindly provided via the Information Centre pages of the IBD Nurse Forum website: www.ibdnurses.com Registration for the site is very Timeframe easy and once registered you can access a great deal of useful information including further examples of job descriptions for IBD & Gastro nurse 2 years posts, business case templates, treatment algorithms, treatment record cards and guidelines, drug checklists, clinical management plans, patient information sheets and details of forthcoming IBD Nurse related meetings. Political Levers: - Below is list of suggested strategies to argue for new or additional IBD Clinical Nurse Specialist (CNS) funding. An example of a protocol for an IBD Specialist Nurse Service devised by Bolton Hospitals NHS Trust can be seen in Appendix 2How to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 4 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 5. 18 week pathways- ‘Buttons to push’ - CNS can free up consultant time for new 18 week patients - 18 week pathway is an opportunity to seek non recurrent funding for CNS - ‘Ask for more than you need’- start negotiations at ‘need two consultants’ with a aim to get one consultant with a supporting CNS and/or dietitian - IBD CNS by doing telephone clinics (if hospital properly refunded for telephone OPD) can reduce face to face chronic disease management follow ups (see Appendix 3) - CNS may provide better triage of patients for gastroenterology- thereby reducing LoS (Impact of specialist care on clinical outcomes for medical emergencies) Clinical Risk - Argue that IBD Nurse Specialist can reduce clinical risk by: appropriate use of steroids, appropriate monitoring of immunosuppressive therapy and safe use of infliximab - The UK IBD Audit has shown that the presence of an IBD Clinical Nurse Specialist correlates with many aspects of good care- e.g. prescribing bone protection agents, prophylactic heparin. If you require the full data, please contact us. NICE guidance - Need an infrastructure to co-ordinate and provide anti-TNF α therapy. Anti-TNF therapy reduces admissions and possibly reduces surgery - Could make a bid for ‘IBD Biologicals Nurse’ - Quality of care issues - Identify the areas of your IBD care which are suboptimal from your local results in the IBD audit (or other sources). See if any of these could be improved by the presence of an IBD Nurse SpecialistHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 5 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 6. Job Plans - IBD Nurse Specialists need to be involved with ward-based training & education of nursing & junior medical colleagues - Offer a primary/secondary care interface. Argue this could reduce OPD attendance for chronic disease management. A suggestion is that GP could directly access the IBD Nurse Specialist for advice on referral or management - Having functional IBD services could provide income protection for PCT from competing ITC/PCTs Research & IBD Clinical Nurse Specialists - 1 session per week is minimum - Demonstrate value added of IBD nurse to cover consultant time whilst on research. - Get trust to understand the finance involved. - Trusts make money on overheads (40%) out of commercial firms. Same argument can be used to fund specialist nurse posts • 33% of sites did not have a dedicated - Define a gastroenterology ward geographically in your hospital -Medical and clinical directors gastroenterology ward (medical or - Set up a system of speciality triage (refer to Moore S et al. -Bed managers surgical). Comment: a dedicated (Impact of specialist care on clinical outcomes for medical -EMU, AMU gastroenterology ward or ward area should emergencies) Clin Med. 2006 May-Jun;6(3):286-93) -Specialist nurses or SpR’s be identifiable at each site. - There should be a daily presence on the Emergency Admission Unit by a member of the gastro team - either a Consultant, SpR or Timeframe Clinical Nurse Specialist. This usually has a marked improvement on specialty triage -1 Year - Nominate SpRs to give them defined roles - Know your supporting data/papers – LoS (length of stay) for ‘gastro patients’ under the care of non-gastroenterologists, again refer to: (Impact of specialist care on clinical outcomes for medical emergencies) - Audit criteria on other wards – determine a care pathway defining practice (see Appendix 4 for an example of a care pathway for the management of acute severe colitis kindly provided by Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust) - Have a system to flag up inpatients at endoscopy who should be transferred to a gastro wardHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 6 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 7. Audit Indicator Suggested choice of action Suggested people to lead or involve • There are not enough toilets with a median - This is a difficult issue to improve because obviously it could -NACC 4.5 beds per toilet. Comment: there should involve extensive ward renovation. However some sites have -Local patient panels be a maximum of 3 beds per toilet. done exactly this by reducing their gastroenterology bed-base to -Estates department increase the number of toilets. Below are suggestions and -Clinical governance lead questions which may arise: -Bed manager / directorate manager / ward manager - Male/Female issue. Politically this has been topical and may be a -Infection control lever to improve the provision of toilets. - Remove beds – less beds or a bay for people with IBD Timeframe - Use the side rooms/ward facilities for patients that have the most urgent need -6 months - Set a standard for new builds/ or ward rebuilds - Look for opportunities to add extra toilets into existing space (to meet standard) - Do units/wards have a budget for building services? - Presume all beds always filled? Are specific toilets allocated to specific (nearest?) beds? - Showers not baths – is that less demanding on space? - Are there any obvious dead areas? - IBD patients should be a priority - Need to avoid CDT (dedicated CDT wards an idea) - Use of NACC/King’s fund/patient power/ to take up argument - National drive - Patient panels: is a one-off cost? - Governance card on risk of cross infection? - Data on CDT - ££ implications. If CDT is a particularly problem then it can be an opportunity to improve toilet provision for both people with CDT and those with other diarrhoeal diseasesHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 7 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 8. Audit Indicator Suggested choice of action Suggested people to lead or involve • Provision of dietetic services is poor with a - Cost benefit analysis re feeding regime median of 2 (IQR 0-5) sessions per week - Identify how an increased dietetic service can increase ‘payment -Patient Panel dedicated to gastroenterology. Comment: by results’ -Dietetics department and IBD patient surveys show dissatisfaction - Regular gastro dietetics update for clinicians dietetics managers with the lack of dietetic services. There - Know sources of potential funding -Managers needs to be improvement in the provision -Commissioners - Extended training for dieticians to enable them to see other of these services. patients and so generate ££ Timeframe - Identify dieticians with specialist interest in Gastroenterology - Identify cause of DNA’s at dietetic clinic – telephone follow up -6 months will lower DNA rate? - Shared posts across trusts or PCTS. One suggestion is that a gastroenterology dietician could provide joint care across primary and secondary care for both coeliac disease and IBD. This could involve clinics in primary care. Argue that increasing dietetic services can reduce the number of outpatient attendances for chronic disease management in celiac disease and IBD thus freeing up other staff to meet 18 week targets. - Review case loads – are they appropriate? - Greater awareness of role of dieticians amongst multi discipline team members - Ensure written into new consultant posts - Patient power e.g. patient panels and NACCHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 8 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 9. • Ileo-anal pouch procedures are performed - If deemed appropriate to stop pouch surgery if number of Timeframe in most sites (72%) but the volume of procedures below standard surgery is low (median 4 [IQR 2-7] per - Problem with small number of patients with pouches is lack of year). Comment: hospitals with a low experience in managing long term complications volume of pouch surgery should consider - Have discussions about whether just 2 colorectal surgeons shall referring to hospitals with a larger volume do pouches. of pouch surgery. - Give patients information with regard to options- local or refer to larger centre - Discuss whether regional pouch MDT meetings can be established Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 9 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 10. • Only 34% of sites have a searchable IBD - Identify systems used within other trusts ( see BSG paper- -IT department database. Comment: Provision of “Databases – are they worth the bother?” by Dr Stephen L Grainger -BSG databases need to improve across the UK accessible via: IBD Database info -Ferring/Rotherham Database to facilitate patient care (e.g. colorectal - Identify the cost savings to be made by having a database cancer surveillance, immunosuppressive - Current model with rheumatology applicable? Timeframe therapy monitoring) and audit - BSG to address gap in database and evaluate best model -2 years - Understand national viewpoint/priority - Contact Ferring/Rotherham database leads via the link above - Databases should be searchable and able to be updated. - Problems and advantages of a database - Can it be set up to flag up warnings if patients have not had WBC entered on regular basis for example? - Who maintains the database? - Can it be linked to pathology/other databases? - Can we or another IT company look at developing a model? - Who inputs the data, can it be updated automatically somehow? - Does it really take up one day per week for a nurse, would a data entry clerk be better placed? - What does Rotherham software interface with? - Do rheumatologists have a national database (looks for adverse events)? - Is there a model to follow? - Driven centrally by BSG? Needs half a day per week. - Veterans system in States – what is that? - What is already being done, we need a dialogue. - Rotherham/Ffering > Seemingly no ideal system at present - Can use currently in conjunction with telephone contact service. - Can hospital letters be incorporated into the system? Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 10 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 11. • Open forum or other meetings with Societies and hospital departments to contact/co-ordinate local meetings - NACC patient groups are uncommon in the UK - NACC www.nacc.org.uk www.nacc.org.uk with only 30% of sites involved in these. - PALS - PALS Comment: IBD teams should be - Colostomy Association encouraged to set up meetings with - The Ileostomy and Internal Pouch Support Group Timeframe patient groups, perhaps on a regional - IBD databases are a method of contacting patient to advertise basis. meetings - Primary care – brief for interested GPs - Expert patient panels/patients panels - Patient satisfaction questionnaires- examples from York and Cardiff (HIPPO) - Patient diaries in hospital Patient panels There are several different approaches to this. One approach is to contact your local NACC chairperson and ask for nominations for a small group (5-8 patients attending your hospital). Meetings should usually include a member of the IBD team - usually an IBD Clinical Nurse Specialist. See the relevant NACC web pages for more information on Patient Panels: (http://www.nacc.org.uk/content/about/patientPanels.asp). Other approaches are: patient initiated and patient lead - but with close liaison with the local IBD Health Service Team or campaigning Patient Panel arising from a threat to local services e.g. reduction in IBD nursing hours - but can develop into a more traditional model when campaigning issue is over. Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 11 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 12. • Only 21% of sites have pathways for - Make a business case for a new consultant with support sessions for Timeframe direct access to psychological support. a Psychologist (plus IBD Clinical Nurse Specialist and Dietitian) Comment: direct referral pathways should - Start small - buy a small number of clinical psychology sessions be available for IBD teams to refer - Put on the back of ‘IBS services’ plus services for TPN as well as directly to psychological support IBD i.e. ‘Gastroenterology Clinical Psychology’ services. - Argue that it may reduce the number of consultant follow ups for this small group of patients with difficult disease. This has been the experience of IBD teams which have psychological support. - Training and ‘cascading’ to other staff e.g. IBD Clinical Nurse Specialist - Highlight the importance of developing ‘Coping mechanisms’ for patients - Could bid on the basis of a hospital-wide ‘chronic disease management’ team - to include support for diabetes and chronic renal failure • 31% of patients admitted with Ulcerative - Having a specialist gastroenterology ward probably reduces re- Timeframe Colitis are not transferred to a specialist admissions and improves quality of care. gastroenterology ward (medical, surgical - There is evidence that specialty triage improves outcomes from or joint). Comment: Triage systems for other UK specialties e.g. respiratory medicine – Respir Med. 2007 IBD should be established to ensure that Apr;101(4):754-61 and Moore S et al. Impact of specialist care on admitted patients are under the care of the clinical outcomes for medical emergencies Clin Med. 2006 May- relevant specialty team. Jun;6(3):286-93). - Non-IBD gastro services need appropriated trained nurses e.g. TPN, upper GI bleeding & chronic liver disease - Concentration of nursing & medical experience/expertise - Clinical risk issues - Patient experience (diaries etc) - Infection control, create a separate CDT ward - CDT reduction a national target Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 12 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 13. • Inpatient mortality was 1.6% (45 Carefully analyse any death possibly related to IBD as per ‘Root Suggested timeframe patients). 25 deaths were directly related cause analysis’ methodology (e.g. National Patient Safety Agency) to Ulcerative Colitis, including 15 that http://www.npsa.nhs.uk/health/resources/root_cause_analysis 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 - Refer to the attached acute severe colitis pathway in (CDT done in 47%). Comment: both Appendix 4 Timeframe stool culture and CDT should be - Discuss with your medical microbiologist about culturing performed in all patients admitted with either fluid aspirated at the time of flexible sigmoidoscopy - 3 months active Ulcerative Colitis. or from culture of mucosal biopsies - Regular review by a specialist nurse (patrol the wards? Care pathway?) - Encourage nurses to spend more time on the ward. - Provide a written protocol for admitted IBD patients. - Clipboard on the end of bed – give to patients also or both as double check? - Written protocol for ward nurses – involve the nurses in that process – Link nurse? - Infection control personnel - Should CDT happen by default? Microbiology • For new diagnoses of Ulcerative Colitis, - Meeting with a pathologist most important endoscopic evaluation was done a median - Consider how you identify a lead GI pathologist? of 2 (IQR 1-5) days from admission. Histology was reported a median of 5 - Direct contact with pathology re urgent biopsies (IQR 2-7) days after endoscopic - Obtaining adequate pathology, see links below: procedure. Comment: In many sites there - Initial Biopsy Diagnosis of Suspected Chronic Idiopathic is a delay in obtaining reported histology. Inflammatory Bowel Disease: For suspected new diagnosis of Ulcerative http://www.bsg.org.uk/pdf_word_docs/ideopathic.pdf Colitis admitted to hospital, histology - A Structured Approach to Colorectal Biopsy Assessment: should be reported within 5 days of http://www.bsg.org.uk/pdf_word_docs/biopsy.pdf biopsies being taken. Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 13 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 14. • 40% of Ulcerative Colitis inpatients did - Important aspect of IBD Specialist nurse and Ward sister in not receive prophylactic heparin. providing education for team. Develop a willingness to Suggested timeframe Comment: in-patients with Ulcerative “patrol” the gastro ward - 3 months Colitis should receive prophylactic - Change drug chart appropriately to include prophylactic heparin. heparin - Pharmacy, involve ward pharmacists in gastro clinics and the development of patient info sheets • For those Ulcerative Colitis patients - Refer to for an example care pathway for acute severe Medical and surgical consultants failing to respond to high dose steroids colitis Appendix 4 Pharmacists (high CRP and high stool frequency after - Add pathway to trust intranet 3 days therapy), surgery was the next - Add pathway to F1/F2 induction pack Suggested timeframe therapy in 42%, 25% had ciclosporin and - Add to F1/F2 palm pilots if they have one 4% anti-TNF-α therapy. Comment: rescue - Clear algorithms- pt selection and SAFETY 3 months medical therapy (ciclosporin or anti-TNF- - Guidelines for the use of ciclosporin from the Royal α therapy) was infrequently used. This an Liverpool University Hospital and a paper on use of area in which participation in clinical ciclosporin by Dr Duria and Dr Hawthorne from Univeristy trials is needed. Functional clinical trials Hospital of Wales, Cardiff networks would be beneficial. - Guidance should be to offer/discuss 2nd line therapy - Involvement of the ward pharmacist is key Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 14 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 15. • The decision to operate was made by a Consultant Colorectal Surgeon should be involved in the decision to consultant colorectal surgeon in 77% of operate and should either perform or assist the operation elective operations and 81% of - There is concern when operation undertaken by a non- emergency operations. 92% elective and specialist without the assistance of Consultant Colorectal 77% emergency operations were Surgeon performed or assisted by consultant - Lower GI “second line” on call for formal advice colorectal surgeons. Comment: consultant - Key is that the Consultant Colorectal Surgeon should colorectal surgeons should be involved in always be involved in the provision of advice to the patient the decision to operate and perform (or and the decision operate not that the operation must always assist) operations for inflammatory bowel be performed directly by a specialist disease - Formal arrangement for “on call” advice - Contractual cover for the consultant advising - Agreed handover of the patients to specialist care the following day after admission - If not senior colorectal then establish a rule for the on call team or the colorectal team that decisions should always be discussed with consultant. - IBD emergency admission: where this leads to an elective operation a while later, the patient should be handed over to specialist - Hospital management agree all IBD patients have to go to a gastroenterologist or colorectal surgeon - Write to all clinical leads • Smoking status was not documented in - Develop pathways for documenting smoking status 15% of cases. Comment: smoking - Contact your local smoking cessation team in the hospital cessation support is an important aspect in to meet and agree a strategy for referring patients with treating people with Crohn’s Disease. Crohn’s disease to smoking cessation clinic support Audit Indicator Suggested choice of action Suggested people to lead or involveHow to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 15 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 16. • Only 52% of patients admitted with - Provide scales on bottom of trolley Crohn’s Disease were weighed and only - Patient’s leaflet with info on importance of monitoring Timeframe 37% were seen by a dietitian. Comment: weight patients admitted with Crohn’s Disease 3 months - Regular meeting with ward sister in IBD > team meetings should be weighed and seen by a dietitian. and link nurse (i.e. one nurse who is nominated as IBD link nurse – how to promote this, what would that role involve?) - Seen by dietician during stay - Referred by who? - Is there at least one session per day? - If not, how to get around that? - Are there shared posts? - Gastro training via BDA > 1 day IBD dietetics course >funding for courses - Short bowl syndrome course. - Make sure there is an hour per day set aside for dietician to view patients. - In written protocol all IBD patients should see a dietician (once a day?) - IBD implementation/steering group to develop a written protocol end of bed forms plus office written protocol. Training decisions as specialists in IBD. - Dieticians IBD Team – Link nurse (dietetics?) Identify training needs > what existing courses are there? • Prophylactic anti-thrombotic therapy was - Important aspect of IBD Specialist nurse and Ward sister in providing education for team. Develop a willingness to Suggested timeframe not given in 38% of cases. Comment: in- patients with Crohn’s Disease should “patrol” the gastro ward - 3 months receive prophylactic heparin - Change drug chart appropriately to include prophylactic heparin - Pharmacy, involve ward pharmacists in gastro clinics and the development of patient info sheets Audit Indicator Suggested choice of action Suggested people to lead or involve stHow to use this document: If you participated in the 1 round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 16 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.
  • 17. • For elective surgery, 12% of cases were This is a controversial area. Below we offer some suggestions done laparoscopically/ laparoscopically- (and problems) to try to improve the availability of assisted. Comment: There is marked laparoscopic surgery for CD resection Timeframe variation geographically in the provision - Concern that there is a lack of trained resource? of laparoscopic surgery for IBD. - Offer the choice to patients/ensure they are told about Laparoscopic surgery should be available alternatives (especially if there is an embedded negative as an option for patients with Crohn’s view among the colorectal team) - may be far away, may be Disease requiring resectional surgery. waiting delays - set up the contractual argument to enable referral - refer to Europe? - need for national action to increase training and availability • patients can call for quicker improvement Research - Research/non-commercial trials Timeframe • Only two Ulcerative Colitis patients - Provision of a research session for at least 1 IBD clinician / failing high dose steroids participated in reasonably sized trust any clinical trial and only ten Crohn’s - Individual clinician to negotiate with line manager Disease patients were on any trial drug on - Need for clinical trials network for IBD admission, both <1% participation. - Negotiate with health technology agency Comment: There seems to be infrequent - Calculation of monies brought into units through clinical participation in clinical research - trials/research work at present. Trusts make money on functional clinical trials networks would overheads (40%) out of commercial firms. Same argument be beneficial. can be used to fund specialist nurse posts. - Need for clinical trials network in IBD - Enter into negotiation for funding with Health Technology agency (http://www.hta.nhsweb.nhs.uk/) rather than rely on goodwill of trust. Opportunity to get things moving. - Local principle investigator should have responsibility to ensure data entered properly. - 1 session per week is minimum - Demonstrate value added of IBD nurse to cover consultant time whilst on research. - Get trust to understand the finance involved.How to use this document: If you participated in the 1st round of the UK IBD Audit use this document in conjunction with your site report to develop your own action plan. If you 17 did not participate we suggest forming a multi-disciplinary team to perform a gap analysis of your current services and perhaps using this document might help. Developed at the RCP, CEEu multi- disciplinary IBD Audit workshop on 3rd April 2007.