Dr%20Deepak%20Kejariwal%20Consultant%20Physician

1
Inpatient care and inpatient experience of adults
with ulcerative colitis in the UK
2
Introduction to the IBD programmeImproving the
care of people with IBD

• Five elements, 20122014
• Inpatient care (1 Jan 31 Dec 2013)
• Assesses the treatment that a patient receives
  when admitted to hospital. Each hospital
  participating in the audit collects information
  on the first 50 patients admitted with ulcerative
  colitis in 2013.
• Inpatient experience (1 Jan 2013 31 Jan 2014)
• Assesses the quality of patient care. Each
  patient included in the inpatient care audit is
  given a questionnaire when they leave hospital.
  They can comment on the care that they received
  and how this made them feel.
• Biological therapy audit (continuous audit)
• Collects information about treatment, delivery,
  disease activity and quality of life in patients
  who are prescribed infliximab or adalimumab for
  IBD.

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Introduction to the IBD programmeImproving the
care of people with IBD

• Five elements, 20122014
• Organisational audit and quality improvement tool
  IBDQIP (1 Feb 31 March 2014)
• A web-based self-assessment that enables
  hospitals to measure their organisation of care
  compared with national service standards. The
  tool identifies areas for improvement and
  facilitates change.
• Quality improvement peer support visits
• A series of visits where hospitals are paired up
  and meet to compare results and identify methods
  for improving the quality of care for patients.
  The IBD programme team supports the clinical
  teams to share best practice and explore new ways
  of working.

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Methodology

• Prospective patient identification
• Ulcerative colitis (UC)
• Reduced dataset
• Up to 50 audited admissions per site

Inclusion criteria Exclusion criteria
Patients admitted for treatment or surgery for UC (including newly diagnosed patients) Primary reason for admission was not for treatment of UC
Patients any age A day case (for an infusion, endoscopy or day surgery procedure)
Patients admitted for longer than 24 hours If the patient stayed overnight but was discharged within 24 hours of admission
Multiple admissions included
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Participation in inpatient care

• 1 January 2013 1 December 2013
• 95 (154/162) adult trusts/ health boards that
  were eligible to take part
• 190 hospital sites took part
• 4359 patients/admissions were audited
• 28 Ulcerative Colitis admissions at University
  Hospital of North Durham

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Key indicators for inpatient care
Key indicators round 4 National results UHND results
Mortality death during admission 0.85 (37/4359) 0 (0/28)
Previous admission in the past 2 years (among emergency and planned admissions for active UC and restricted to first admission only) 31 (854/2778) 21 (3/14)
Active UC admissions and no UC medication on admission (excludes new diagnoses) 11 (352/3065) 7 (1/14)
Seen by IBD nurse (among emergency admissions) 49 (1657/3410) 40 (8/20)
Stool samples sent for SSC and CDT (among emergency admissions where the patient had diarrhoea) SSC 80 (2060/2565) CDT 76 (1940/2565) SSC 94 (16/17) CDT 82 (14/17)
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Key indicators for inpatient care
Key indicators round 4 National results UHND results
Positive stool sample SSC 3 (57/2060) CDT 4 (79/1940) SSC 13 (2/16) CDT 21 (3/14)
Nutritional screening during admissiona 82 (3566/4359) 100 (28/28)
Seen by a dietitian during admissiona 40 (1449/3635) 93 (25/27)
Prophylactic heparin prescribed (excluding elective surgical admission) 90 (3560/3952) 95 (20/21)
Ciclosporin/anti-TNFa prescribed following failure to respond to corticosteroids Ciclosporin 22 (268/1226) Anti-TNFa 42 (519/1226) Ciclosporin 25 (2/8) Anti-TNFa 13 (1/8)
a Excludes from the denominator admissions that
were not applicable to the question
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Key indicators for inpatient care
Key indicators round 4 National results Your site results
Response to ciclosporin/anti-TNFa treatmenta Ciclosporin 73 (195/268) Anti-TNFa 84 (437/519) Ciclosporin 50 (1/2) Anti-TNFa 100 (1/1)
Surgery during admission among non-elective surgical admissions 12 (442/3784) 38 (8/21)
Bone protection prescribed when discharged home on steroids 74 (2553/3448) 70 (14/20)
Medication(s) not started or increased in the clinic appointment prior to admission. Includes 5-ASA, steroid, topical or immunosuppressant therapy (among admissions where the patient had active UC at their last clinic appointment and were not admitted to hospital) 42 (556/1329) 50 (4/8)
a Response to treatment is defined as not having
had surgery and not having died during admission
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Patients who had surgery

• 8 patients who had surgery
• 2 patients were semi-elective proctectomy (wrong
  coding)
• 2 failed ciclosporin
• 1 prev Aza pancreatitis, on MMF for sarcoidosis-
  so appropriate
• 1- not discussed in MDT
• 2 notes not available

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Case 1- Not discussed in MDT

• Admitted Apr 2013 (on Monday)
• Bloody Diarrhoea 16times a day and abd pain,
  raised CRP Diag- IBD. Plan- stool culture and
  AXR
• D3- Hb-7- Transfused 2 units
• D4- FS- Colitis. Started on IV Hydrocortisone by
  gastro
• D6- Hb 7- transfused 3 units
• D8- ? Ciclosporin.
• D9- D/w Gastro. Felt inappropriate as CT showed ?
  Splenic abscess

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Key indicators for inpatient care
Key indicators round 4 National results UHND results
No steroid-sparing therapies tried for patients on steroids gt3 months (Q6.2.2 d) 22 (151/684) 33 (2/6)
No treatment provided for iron deficiency (Q6.3.3) 56 (783/1406) 57 (4/7)
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Outcomes of treatment escalation in UC
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Inpatient care audit recommendations

1. All outpatients with UC should have their disease
   activity accurately assessed (eg using symptoms
   and faecal calprotectin), and treatment should be
   initiated or escalated in those with active
   disease. Early intervention may prevent
   admission.
2. All patients with a new diagnosis of UC, those
   for whom the use of anti-TNFa is considered and
   those requiring additional information should be
   seen by an IBD nurse during admission.
3. IBD services should ensure that inpatient IBD
   care provided by the IBD nurse is appropriately
   resourced in line with IBD Standard A1 (1.5
   whole-time equivalent nurse per 250,000
   population).
4. All IBD patients admitted to hospital should be
   weighed and their nutritional needs assessed, in
   line with IBD Standard A10.
5. Bone protection should be prescribed to all
   patients with UC who receive corticosteroids.

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Inpatient care audit recommendations

1. Heparin should be given to all patients for whom
   it is not contraindicated, to reduce the risk of
   thromboembolism.
2. All patients on steroids for longer than 3 months
   should be considered for steroid-sparing agents
   such as azathioprine.
3. Anaemia should be actively investigated, and the
   cause should be identified and treated
   appropriately.
4. Further national audit in IBD should be
   commissioned.

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Participation in inpatient experience

• 1 January 2013 31 January 2014
• 154/162 (95) trusts/health boards
• 190 hospitals
• 1687 questionnaires returned (1550 included in
  national analysis)
• UHND 13 questionnaires returned

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Key indicators for inpatient experience
Key indicators round 4 National results UHND results
Overall how would you rate the care you received? Excellent 47 (690/1475) Excellent 54 (7/13)
Did you have confidence and trust in the doctors treating you? Yes, always 75 (1098/1470) Yes, always 77 (10/13)
Did the patient receive a visit from a specialist nurse? No 28 (417/1471) No 15 (2/13)
Was the patient visited by a dietitian? No 62 (915/1476) No 69 (9/13)
Were you ever in pain? Yes 78 (1154/1478) Yes 77 (10/13)
Do you think the hospital staff did everything the could to control your pain? Yes, definitely 66 (763/1148) Yes, definitely 90 (9/10)
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Key indicators for inpatient experience
Key indicators round 4 National results UHND results
In your opinion how clean was the hospital room or ward you were in? Very clean 62 (914/1473) Very clean 77 (10/13)
How would you rate how well the doctors and nurses worked together? Excellent 40 (584/1472) Excellent 38 (5/13)
Did a member of staff tell you about any danger signals you should watch out for after you went home? No 33 (477/1466) No 54 (7/13)
Do you feel that you received enough information from the hospital on how to manage your condition after your discharge? Yes, definitely 47 (683/1454) Yes, definitely 83 (10/12)
Would you recommend this hospital to your family and friends? Yes, definitely 62 (910/1465) Yes, definitely 69 (9/13)
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Patient experience across core domains of acute
inpatient care
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Inpatient experience quotes
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Inpatient experience quotes
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Inpatient experience recommendations

1. All UC inpatients should receive input from
   specialist multidisciplinary teams with
   experience of managing such complex disorders.
   This will maximise the opportunity for provision
   of consistent and coordinated care.
2. Local IBD teams should consider whether the
   general nursing staff have sufficient awareness
   and knowledge of IBD, and initiate appropriate
   educational interventions and care pathways to
   support high-quality nursing. The routine
   involvement of specialist IBD nurses in the
   day-to-day care of IBD patients at ward level is
   seen as a potential driver to improve the overall
   experience of nursing care.
3. All admitted patients with active UC require
   routine documentation of nutritional intake and
   weight. Nursing care plans should identify
   nutrition as a key element of day-to-day care.
   Food provided should be appropriate to patients
   dietary needs. Standard A5 of the IBD standards1
   states that access to a dietitian should be
   available to all IBD patients.

1 IBD Standards Group. Standards for the
healthcare of people who have inflammatory bowel
disease (IBD Standards), 2013 update.
www.ibdstandards.org.uk
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Inpatient experience recommendations

1. Ward medical and nursing teams should review
   their local policies and current practice with
   regard to the frequency and effectiveness of pain
   assessment and provision of analgesia.
2. Discharge policies for IBD patients require local
   review to ensure that patients receive
   high-quality pre-discharge information regarding
   medication, self-care and follow-up plans. In
   particular, improvements are needed in the
   provision of information about potential drug
   side effects and the warning signs of which to be
   aware after discharge.

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Your three key areas for local change
Local key area identified What action is needed to facilitate this change? Who will be responsible? How and when will you review this action?
1. Treatment of anaemia Write local treatment algorithm and circulate to MDT Consultant gastroenterologist and IBD nurse Sep 2014
2.
3.
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Acknowledgements

• Thank you to all the hospital-based staff who
  contributed towards case note retrieval and data
  collection, and distributed the inpatient
  experience questionnaires.
• For further information, contact
• ibd.audit_at_rcplondon.ac.uk