UK IBD Audit 3rd Round

1
UK IBD Audit 3rd Round

• Comparison of
• (Your Site Name) results against the National
  Results for Clinical Audit of Adult IBD Inpatient
  Care in the UK

2
Participation in round 3

• 198 adults sites across the UK entered clinical
  audit data
• England 161 sites
• Jersey 1 site
• Northern Ireland 10 sites
• Scotland 11 sites
• Wales 15 sites
• A site typically constitutes a single hospital
  within a health board/trust. Where a health
  board/trust has more than one hospital offering
  independent IBD services they entered data for
  separate sites. Some institutions running a
  coordinated IBD service across two or more
  hospitals with the same staff took part as one
  health board/trust-wide site

3
Publication of results

• Data was entered by sites onto a password
  protected audit web tool under the direction of
  a designated site lead, in almost every case a
  Consultant Gastroenterologist
• Data entered between 1 September 2010 and 31
  August 2011
• The results provide contemporary UK-wide data and
  all participating sites have received
  site-specific reports which will included local
  data for comparison against national averages
  (use this data to populate the your site column
  in all following tables)
• The full National Report was launched on 21
  February 2012

4

• Key Results Ulcerative colitis

Adult IBD Care Ulcerative Colitis. Table (3) of
National Report UK Results v Your Site 2010 (page
8)
5
Key Results Ulcerative colitisTable (3) of
National Report UK Results v Your Site 2010
2010 UK Results (3049 admissions in total of which 2554 elective) Your Site 2010
Did the patient die during the admission? 28/3049 (0.09) ??
Where the patient had a pre-admission diagnosis of UC had they been admitted for UC in the 2 years prior to the audited admission? 656/2002 (33) ??
Were the non-elective patients seen by an IBD nurse during their admission? 1067/2554 (42) ??
Were standard Stool Culture (SSC) and Clostridium Difficile Toxin (CDT) samples requested, in non-elective patients with diarrhoea (recorded in the first full day following admission)? SSC 1537/1937 (79) CDT 1414/1937 (73) SSC ?? CDT ??
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Key Results Ulcerative colitisTable (3) of
National Report UK Results v Your Site 2010
2010 UK Results (3049 admissions in total of which 2554 elective) Your Site 2010
Were the stool samples positive? SSC 33/1537 (2) CDT 22/1414 (2) SSC ?? CDT ??
Was prophylactic Heparin prescribed? 2668/3049 (88) ??
Was the patient prescribed Ciclosporin or Anti TNF during the admission? (non electives who did not respond to corticosteriods? Ciclosporin 225/763 (29.5) Anti TNF 160/763 (21) Ciclosporin ?? Anti TNF ??
Did the patient respond to treatment with Ciclosporin or Anti TNF? Ciclosporin 141/225 (63) Anti TNF 132/160 (82.5) Ciclosporin ?? Anti TNF ??
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Key Results Ulcerative colitisTable (3) of
National Report UK Results v Your Site 2010
2010 UK Results (3049 admissions in total of which 2554 elective) 2010 UK Results (3049 admissions in total of which 2554 elective) Your Site 2010 Your Site 2010
In patients undergoing surgery, was this undertaken laparoscopically? Elective 205/490 (42) Elective ??
In patients undergoing surgery, was this undertaken laparoscopically? Non-Elective 98/317 (31) Non-Elective ??
If the patient was prescribed steroids on discharge, were they also prescribed bone protection agents? 1443/2194 (66) 1443/2194 (66) ?? ??
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• Key Findings Ulcerative colitis

Ulcerative Colitis findings relate to key
results indicated in Table(3) Adult IBD Care
Ulcerative Colitis. UK Results v Your Site 2010
(page 10)
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Key Findings Ulcerative colitis

• Mortality rate has halved over the 3 rounds
• Statistically significant reduction in the number
  of patients who had been admitted to hospital for
  UC in the 2 years prior to the audited admission
• Stool samples are now being sent significantly
  more frequently for both Standard Stool Cultures
  (SSC) and Clostridium Difficile Toxin (CDT), for
  UC patients admitted with diarrhoea
• Significant reduction in the number of stool
  samples positive for CDT
• 5. Prophylactic Heparin is being prescribed more
  frequently
• 6. For patients failing to respond to IV
  steroids, the use of anti-TNF therapy has
  increased significantly and the use of
  Ciclosporin has dropped slightly
• 7. Significant improvement in response rates for
  anti-TNF therapy across rounds with an improved
  but non-significant rise in the response rates
  for Ciclosporin
• 8. Prescription of bone protection for patients
  discharged on steroids has increased

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• Key Results Crohns disease

Adult IBD Care Crohns Disease. Table (4) of
National Report UK Results v Your Site 2010
(page 9)
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Key Results Crohns diseaseTable (4) of
National Report UK Results v Your Site 2010
2010 UK Results (3122 admissions in total of which 2571 elective) Your Site 2010
Did the patient die during the admission? 21/3122 (0.7) ??
Was the patient admitted under the care of a gastroenterology specialist? 983/2571 (38) ??
Did the patient see an IBD nurse during their admission? 905/2571 (35) ??
Was Anti-TNF therapy prescribed during the admission? (only includes non-elective patients indicated as not receiving Anti-TNF on admission) 186/2509 (7.4) ??
In patient started on Anti TNF during this admission, did they respond to the treatment? 163/186 (87.6) ??
Was prophylactic Heparin prescribed? 2708/3122 (87) ??
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Key Results Crohns diseaseTable (4) of
National Report UK Results v Your Site 2010
2010 UK Results (3122 admissions in total of which 2571 elective) Your Site 2010
Were Standard Stool Culture (SSC) and Clostridium Difficile Toxin (CDT) samples requested, in non-elective patients with diarrhoea (recorded in the first full day following admission)? SSC 726/1309 (55) CDT 657/1309 (50) SSC ?? CDT ??
Were the non-elective patients seen by a dietician during the admission? 980/2571 (38) XX
Were the non-elective patients weighed during the admission? 1846/2571 (72) XX
In patients surgery, was this undertaken laparoscopically? 326/1020 (32) XX
Does the patient smoke? 931/3122 (30) XX
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Key Results Crohns diseaseTable (4) of
National Report UK Results v Your Site 2010
2010 UK Results (3122 admissions in total of which 2571 elective) Your Site 2010
How many patients had been taking steroids (at any time) for longer than 3 months continuously prior to the admission? 664/3122 (21) ??
Was bone protection used in patients steroids for more than 3 months continuously? 404/600 (67) ??
What treatment was the patient taking for Crohns disease on admission? What treatment was the patient taking for Crohns disease on admission? What treatment was the patient taking for Crohns disease on admission?
5-ASA (both alone or in combination with any other medication) 1073/3122 (34) ??
5-ASA only 404/3122 (13) ??
5-ASA without any of Azathioprine, Mercaptopurine, Methotrexate or AntiTNF 662/3122 (21) ??
Either Azathioprine, Mercaptopurine or Methotrexate alone 315/3122 (10) ??
Either of Azathioprine, Mercaptopurine or Methotrexate AND Anti-TNF 121/3122 (4) ??
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• Key Findings Crohns disease

Crohns Disease findings relate to key results
indicated in Table(4) Adult IBD Care Crohns
Disease. UK Results v Your Site 2010 (page 10)
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• Key Findings Crohns disease
• Use of Anti-TNF therapy for patients admitted
  with CD has doubled over 3 rounds but use remains
  at a relatively low level overall
• For CD there has not been the same increase as
  observed for UC in the rates of stool samples
  sent for Standard Stool cultures and Clostridium
  Difficile Toxin in patients admitted with
  diarrhoea
• 13 of patients were taking 5-ASA drugs as the
  sole medication for their CD on admission. A
  further 21.2 were taking 5-ASA drugs with other
  medication but not in conjunction with any of
  Azathioprine, Mercaptopurine, Methotrexate or
  Anti-TNF therapy
• 63.3 of patients were not taking any of
  Azathioprine, Mercaptopurine, Methotrexate or
  Anti-TNF therapy on admission
• Significantly more patients were weighed during
  their admission
• The number of patients seen by a dietician during
  their admission has continued to rise across
  rounds but remains at a low level overall
• Just under a third of patients with CD admitted
  to hospital are smokers. This has not changed
  over the 3 rounds of the IBD audit

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Recommendations for Adult IBD Care - IBD Services
based on findings collated for Ulcerative Colitis
Crohns Disease as detailed in tables (3) (4)
of National Report (page 11)

• Key Recommendations

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Key Recommendations

• All IBD patients with diarrhoea should have
  stools sampled for both SSC and CDT testing
• All appropriate IBD patients should be given
  heparin to reduce the risk of thromboembolism
• Clinicians should consider the use of rescue
  medical therapy for patients that do not respond
  to IV steroids
• Where IBD services have a IBD nurse specialist
  provision, the nurse should always be made aware
  of any IBD inpatient that is planned to commence
  Anti-TNF treatment to ensure appropriate
  counselling and screening is undertaken prior to
  the infusion
• Bone protection should be prescribed to all
  patients who receive corticosteroids
• Further long term data is needed on the safety,
  efficacy and appropriateness of use of Anti-TNF
  drugs. IBD Services are encouraged to participate
  in the ongoing Biologics audit element of the UK
  IBD audit
• IBD Services are to review the maintenance
  strategies for CD

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Key Recommendations continued

• Use of immunomodulators and biological therapies,
  in keeping with the 2011 BSG Guidelines for the
  management of inflammatory bowel disease in
  adults, will help to reduce long-term steroid use
  and the need for admission
• A dietician should see all CD inpatients and a
  multidisciplinary nutrition support team must be
  available to IBD Services to offer advice on
  those patients who may require more complex
  enteral and/or parenteral nutritional support
• Smoking cessation is an important factor in
  maintaining remission and in reducing the risk of
  relapse in CD. IBD Services should do more to
  encourage patients with CD to engage with formal
  smoking cessation services

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• Key Indicator Data

• The table in section 5 (page 35) of the report
  gives named data in alphabetical order of
  participating site (divided by health board /
  SHA)
• These data items were agreed by the UK IBD Audit
  Steering Group as reflecting the questions of
  particular importance to IBD patients
• The combined data from all 198 sites are shown
  for comparison
• These results should be interpreted within the
  context of the fact that many sites entered a
  relatively small number of cases to the audit and
  therefore percentages should be reviewed
  alongside the actual number of cases submitted

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• Key Indicator Data

Key Indicators How many cases were entered to the UK IBD Audit? How many cases were entered to the UK IBD Audit? Was the patient seen by a gastroenterologist during their admission? (this does not apply to patients who were admitted for either elective surgery or who were under the direct care of a surgeon) Was the patient seen by a gastroenterologist during their admission? (this does not apply to patients who were admitted for either elective surgery or who were under the direct care of a surgeon) In patient with diarrhoea, was stool sample sent for Standard Stool Culture (SSC)? (SSC is a test to identify bacteria or viruses that may be causing an infection) In patient with diarrhoea, was stool sample sent for Standard Stool Culture (SSC)? (SSC is a test to identify bacteria or viruses that may be causing an infection) Was prophylactic Heparin prescribed? (this medication is used to prevent and treat blood clots) Was prophylactic Heparin prescribed? (this medication is used to prevent and treat blood clots)
Ulcerative Colitis Crohns Disease Ulcerative Colitis Crohns Disease Ulcerative Colitis Crohns Disease Ulcerative Colitis Crohns Disease
UK Results 2010 Median 18 Median 20 Yes 2258 (88) Yes 1994 (79) Yes 1537 (79) Yes 726 (55) Yes 2268 (88) Yes 2708 (87)
Your Site Results ?? ?? ?? ?? ?? ?? ?? ??
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• Key Indicator Data

Key Indicators Was the patient prescribed rescue therapy during the admission? (Drug that decrease the action of the bodys immune system) If the patient was prescribed steroids on discharge, were they also prescribed bone protection agents? If the patient was prescribed steroids on discharge, were they also prescribed bone protection agents? Was the patient weighed during admission? (Crohns disease only) Was the patient seen by a dietician during their admission? (Crohns disease only)
Ulcerative Colitis Ulcerative Colitis Crohns Disease CD Only CD Only
UK Results 2010 Yes 397 (38.7) Yes 1443 (66) Yes 1022 (58) Yes 1846 (72) Yes 980 (38)
Your Site Results ?? ?? ?? ?? ??
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Summary of National Results

• These results highlight
• Clear evidence of sustained improvements in
  quality of care for IBD patients
• Substantial continued improvement seen
  particularly for patients admitted with UC
  mortality rates halved over 3 rounds of the audit
  
• Readmission rates lowered
• Percentage of patients seen by an IBD nurse
  specialist during admission doubled since first
  round
• Collection of stool samples for SSC and CDT
  continued to improve halving of positive CDT
  samples noted
• Prescription of prophylactic Heparin continued to
  rise
• Numerical but not statistically significant
  reduction in mortality for patients admitted with
  CD
• Rate of operations undertaken laparoscopically
  increased significantly across rounds
• Use of anti-TNF therapy for patients admitted
  with CD doubled since first round
• 60 of patients with CD still not seen by a
  dietician during admission
• Rates of collection of stool samples for SSC and
  CDT increased across rounds one and two but
  fallen back in this round
• UK IBD Audit continues to demonstrate significant
  changes in the delivery of IBD care over a
  relatively short time period but there remains
  more to be done.

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Action Plan
National Recommendation Action Required Staff Responsible Progress at Your Site
1. Sites should aim to continue to deliver high quality care for patients with UC and CD, including collecting stool specimens and giving Prophylactic Heparin to all appropriate inpatients Submission of all relevant local cases to the UK IBD Audit All IBD patients with diarrhoea should be considered for stool sample collection for SSC and CDT All IBD patients should be prescribed Heparin, unless contraindicated UK IBD Audit Clinical Lead Consultant Gastroenterologists Consultant Gastroenterologists
2. Sites should consider the value of rescue therapy for patients hat do not respond to intravenous steroids. d) In patients with no/poor response to steroid treatment, Ciclosporin/Anti-TNF should be considered Consultant Gastroenterologists
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Action Plan
National Recommendation Action Required Staff Responsible Progress at Your Site
3. Bone protection should be prescribed to all patients who receive corticosteroids Local policy should dictate that bone protection agents are prescribed to all IBD patients started on steroid treatment Consultant Gastroenterologists/Hospital Policy Managers
4. Sites should continue to ensure appropriate use of specialist ward areas f) All IBD patients should be admitted directly to specialist gastroenterology wards Bed Managers/Ward Staff
5. Further audit is needed on the use of Anti-TNF drugs and sites are encouraged to participate in the ongoing UK IBD Biologics Audit g) Any site providing biological treatment (Infliximab or Adalimumab) to IBD patients, should be registered to participate in the UK IBD Biologics Audit (or a relevant alternative) UK IBD Clinical Lead
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Action Plan
National Recommendation Action Required Staff Responsible Progress at Your Site
6. Sites are strongly encouraged to review the therapy received by all IBD patients. 5-ASA drugs may be stopped in many CD cases and the use of immunomodulators and biologics in keeping with national clinical guidance will help to reduce long-term steroid use and the need for admission Local review of existing evidence should be undertaken to inform any continued use of 5-ASA drugs in CD patients i) Any patient on long-term steroids (gt3 months) should be under regular review Consultant Gastroenterologists Consultant Gastroenterologists
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Action Plan
National Recommendation Action Required Staff Responsible Progress at Your Site
7. Sites should continue to focus on the nutritional needs of patients with CD ensuring they have appropriate dietetic support All CD inpatients should have their weight regularly monitored (weekly/daily?) Business cases should put forward to promote the need for further dietetic support for IBD patients Nursing Staff/Healthcare Assistants Consultant Gastroenterologists
8. Patients with CD who smoke should be encouraged to engage with formal smoking cessation services l) Leaflets promoting local smoking cessation services should be handed to all CD inpatients that smoke All members of the IBD Team
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Your 3 key areas for local change
Local key area identified What action needs to occur to facilitate this change? Who will be responsible? How and when will you review this action?
1.
2.
3.
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The Future

• Data entry for the biologics audit element of the
  round 3 UK IBD Audit continues. An interim report
  will be published in June 2012
• Enter data for your IBD patients receiving
  biological therapy at www.ibdbiologicsaudit.org
• Sites are encouraged to access and contribute
  towards the Shared Document Store on the IBD
  Quality Improvement Project (IBDQIP) website
  www.ibdqip.co.uk which provides tools that sites
  can use to implement change within their own IBD
  Service.

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Acknowledgements

• Most importantly thank you to all of the people
  who worked within Your Site towards collating
  and entering the data
• All members of the UK IBD Audit Steering Group
• For further information contact
• ibd.audit_at_rcplondon.ac.uk