Inpatient care and inpatient experience of adults with ulcerative colitis in the UK

1. Inpatient care and inpatient experience of adults with ulcerative colitis in the UK Dr Deepak Kejariwal Consultant Physician Aug 2014

2. Introduction to the IBD programme‘Improving the care of people with IBD’ Five elements, 2012–2014 • 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.

3. Introduction to the IBD programme‘Improving the care of people with IBD’ Five elements, 2012–2014 • 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.

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

5. 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

6. Key indicators for inpatient care

7. Key indicators for inpatient care a Excludes from the denominator admissions that were not applicable to the question

8. Key indicators for inpatient care a Response to treatment is defined as not having had surgery and not having died during admission

9. 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

10. 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

11. Key indicators for inpatient care

12. Outcomes of treatment escalation in UC

13. Inpatient care audit recommendations • 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. • All patients with a new diagnosis of UC, those for whom the use of anti‐TNFα is considered and those requiring additional information should be seen by an IBD nurse during admission. • 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). • All IBD patients admitted to hospital should be weighed and their nutritional needs assessed, in line with IBD Standard A10. • Bone protection should be prescribed to all patients with UC who receive corticosteroids.

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

15. 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

16. Key indicators for inpatient experience

17. Key indicators for inpatient experience

18. Patient experience across core domains of acute inpatient care

19. Inpatient experience quotes

20. Inpatient experience quotes

21. Inpatient experience recommendations • 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. • 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. • 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

22. Inpatient experience recommendations • 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. • 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.

23. Your three key areas for local change

24. 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@rcplondon.ac.uk