Inpatient care and inpatient experience of adults with ulcerative colitis in the UK [Presenter / title] [Date of presentation] Introduction to the IBD programme ‘Improving the care of people with IBD’ Five elements, 2012–2014 1. 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. 2. 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. 3. 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. Introduction to the IBD programme ‘Improving the care of people with IBD’ Five elements, 2012–2014 4. 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. 5. 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. 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 Primary reason for admission was not for treatment of UC patients) Patients any age A day case (for an infusion, endoscopy or day surgery procedure) Patients admitted for longer than 24 hours Multiple admissions included If the patient stayed overnight but was discharged within 24 hours of admission 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 admissions were audited • [Your site’s number of admissions] Key indicators for inpatient care Your site level data for this table can be found in your local site report (Section 2, Table 3) Key indicators round 4 National results Your site results Mortality – death during admission 0.85% (37/4359) % (n/N) Previous admission in the past 2 years 31% (854/2778) % (n/N) Active UC admissions and no UC medication on admission (excludes new diagnoses) 11% (352/3065) % (n/N) Seen by IBD nurse (among emergency admissions) 49% (1657/3410) % (n/N) Stool samples sent for SSC and CDT SSC: 80% (2060/2565) CDT: 76% (1940/2565) SSC: % (n/N) CDT % (n/N) (among emergency and planned admissions for active UC and restricted to first admission only) (among emergency admissions where the patient had diarrhoea) Key indicators for inpatient care Your site level data for this table can be found in your local site report (Section 2, Table 3) Key indicators round 4 National results Your site results Positive stool sample SSC: 3% (57/2060) CDT: 4% (79/1940) SSC: % (n/N) CDT: % (n/N) Nutritional screening during admissiona 82% (3566/4359) % (n/N) Seen by a dietitian during admissiona 40% (1449/3635) % (n/N) Prophylactic heparin prescribed 90% (3560/3952) % (n/N) Ciclosporin: 22% (268/1226) Anti‐TNFα: 42% (519/1226) Ciclosporin: % (n/N) Anti‐TNFα: % (n/N) (excluding elective surgical admission) Ciclosporin/anti‐TNFα prescribed following failure to respond to corticosteroids a Excludes from the denominator admissions that were not applicable to the question Key indicators for inpatient care Your site level data for this table can be found in your local site report (Section 2, Table 3) Key indicators round 4 National results Your site results Response to ciclosporin / anti-TNFα treatmenta 80% (627/780) % (n/N) Surgery during admission among non‐elective surgical admissions 12% (442/3784) % (n/N) Bone protection prescribed when discharged 74% (2553/3448) home on steroids Medication(s) not started or increased in the clinic appointment prior to admission. Includes: 5‐ASA, steroid, topical or immunosuppressant therapy 42% (556/1329) (among admissions where the patient had active UC at their last clinic appointment and were not admitted to hospital) a Response to treatment is defined as not having had surgery and not having died during admission % (n/N) % (n/N) Key indicators for inpatient care Your site level data for this table can be found in your local site report, within the national data table (from page 23). Individual question numbers are provided below Key indicators round 4 National results Your site results No steroid-sparing therapies tried for patients on steroids >3 months 22% (151/684) % (n/N) 56% (783/1406) % (n/N) (National data table Q6.2.2 d) No treatment provided for iron deficiency (National data table Q6.3.3) Outcomes of treatment escalation in UC 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‐TNFα 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. Inpatient care audit recommendations 6. Heparin should be given to all patients for whom it is not contraindicated, to reduce the risk of thromboembolism. 7. All patients on steroids for longer than 3 months should be considered for steroid‐sparing agents such as azathioprine. 8. Anaemia should be actively investigated, and the cause should be identified and treated appropriately. 9. Further national audit in IBD should be commissioned. 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) • Your site’s number of questionnaires returned Key indicators for inpatient experience Key indicators round 4 National results Your site results Overall how would you rate the care you received? Excellent = 47% (690/1475) Excellent = % (n/N) Did you have confidence and trust in the doctors treating you? Yes, always = 75% (1098/1470) Yes, always = % (n/N) Did the patient receive a visit from a specialist nurse? No = 28% (417/1471) No = % (n/N) Was the patient visited by a dietitian? No = 62% (915/1476) No = % (n/N) Were you ever in pain? Yes = 78% (1154/1478) Yes = % (n/N) Do you think the hospital staff did everything Yes, definitely = 66% (763/1148) the could to control your pain? Yes, definitely = % (n/N) Key indicators for inpatient experience Key indicators round 4 National results Your site results In your opinion how clean was the hospital room or ward you were in? Very clean = 62% (914/1473) Very clean = % (n/N) How would you rate how well the doctors and nurses worked together? Excellent = 40% (584/1472) Excellent = % (n/N) No = Did a member of staff tell you about any danger signals you should watch out for after 33% (477/1466) you went home? No = % (n/N) 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 = % (n/N) Would you recommend this hospital to your family and friends? Yes, definitely = 62% (910/1465) Yes, definitely = % (n/N) Patient experience across core domains of acute inpatient care Inpatient experience quotes Inpatient experience quotes 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 Inpatient experience recommendations 4. 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. 5. 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. Your three key areas for local change Local key area identified What action is needed Who will be to facilitate this responsible? change? 1. Treatment of anaemia Write local treatment algorithm and circulate to MDT 2. 3. How and when will you review this action? Consultant Sep 2014 gastroenterologist and IBD nurse 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