UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Help Notes for Adult Crohn’s Disease (Inpatients)

Patient Identification. Patients should be included if they have a primary discharge diagnosis of Crohn’s Disease that matches the ICD-Codes provided
We know that there are often problems with miscoding so it will ultimately be the responsibility of the clinical lead at each site, or other designated IBD team
members under their guidance, to decide whether the admission was primarily for Crohn’s Disease and if the case note details should therefore be audited.

Only include admissions of >24 hours. Do not enter data for day cases such as for endoscopy or drug infusions.

We know that many sites choose to complete the details of each admission on the paper proforma prior to transferring the details onto the website.
A general rule when completing the form is that where you see boxes as options for answers then you can choose multiple options for answers (i.e. all that
apply). Circle options indicate that a single option must be chosen. Where you see a combination of boxes with a circle choosing the answer option next to a
circle will mean that none of the answer options with a box next to them can therefore be chosen.
Question
Data Item
Audit Help Notes
Number
Pre-section Patient Demographics
A
Auditor Discipline:
a)
b)
c)
d)
e)
f)
Please enter the discipline of each individual who made a significant contribution to the data collection and entry.
Consultant
Other medical staff
Nurse
Manager
Clinical Audit
Other, please specify
B
Patient Audit Number:
This is automatically generated when you start to enter a new case onto the UK IBD Audit data entry web tool. Please
keep a record of the number so that you have a trail back to the appropriate patient should you need to refer back to
the case notes
C
What was the patient’s age
at admission?
Enter the age of the patient at the date of the admission to hospital.
D
Gender:
Male / Female
Indicate male or female
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Section 1: Admission / Mortality
1.1
1.1.1
Admission
What was the date of
admission to this hospital?
Please enter the date of admission to your hospital in the format:
day (DD), month (MM) year (YYYY) DD/MM/YYYY
Only enter details of one admission per patient even if they were admitted more than once during the audit period,
that being the admission closest to 1st September 2010.
1.1.2
What was the primary
reason for admission?
a) Emergency admission
for active CD
b) Planned admission for
active CD
c) Elective admission for
surgery
d) New diagnosis of active
Crohn’s Disease
e) Transferred from another
site for surgery
f) Transferred from another
site for further medical
management
1.1.3
Which specialty was
responsible for the
patient's care 24 hours
after admission?
a) Acute Medicine
b) Gastroenterology
c) Colorectal Surgery
d) Geriatrics
e) General Medicine
f) General Surgery
g) Other, please specify
Source: This will be found on electronic patient management systems and within medical and nursing notes
a) Emergency admission for active CD: means acute admission from GP/A&E/other hospital
b) Planned admission for active CD: patient seen as outpatient or by GP and admission arranged by hospital.
c) Elective admission for surgery: surgery planned prior to the admission
d) New diagnosis of active Crohn’s Disease
e) Transferred from another site for surgery
f) Transferred from another site for further medical management
*If IBD was not the primary reason for admission please discard the patient’s notes, and move on to the next
applicable patient.
If the primary reason for admission is option c) Elective admission for surgery, then a number of subsequent
questions in the dataset do not need to be answered. By section these are:
Section 1, questions 1.1.3 through to 1.1.7i
Section 2, the entire section can be ignored
Section 3, ignore all questions in section 3 apart from 3.1.1 and 3.3.2
This can be difficult to clearly assess but we want to determine whose care the patient was under from the period 24
hours after the initial admission to hospital.
Source: Which specialty the patient is under can be obtained from case note entries by specialist teams (consultant,
SpR, F1, F2 or other grade), from nursing notes or hospital transfer notes; it can also be inferred from transfer to a
specialist ward.
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.1.4
1.1.5
1.1.6
1.1.7
What date was the patient
first seen by a Consultant
Gastroenterologist?
Enter the date when the patient was first seen by a Consultant Gastroenterologist during the admission.
‘Seen by’ includes direct hand-written entries by consultants, typed letters or where noted by another member of the
team e.g. ‘patient reviewed by Dr…’
__/__/____
Not seen
Not required
If the patient was not seen by a Consultant Gastroenterologist during the admission enter ‘not seen’.
What date was the patient
first seen by a Consultant
Colorectal Surgeon?
You have an additional option to indicate that review by a consultant gastroenterologist was not required, for instance
if admitted under the direct care of a Consultant Colorectal Surgeon. To be able to tick ‘Not Required’ on the audit
website you will need to select ‘Not Seen’ first, however we would like to confirm that if this is done the answer will be
considered as ‘Not Required’ during data analysis.
Source: From medical, nursing or therapy records
Enter the date when the patient was first seen by a Consultant Colorectal Surgeon during the admission.
‘Seen by’ includes direct hand-written entries by consultants, typed letters or where noted by another member of the
team e.g. ‘patient reviewed by Mr / Miss…’
__/__/____
Not seen
Not required
If the patient was not seen by a Consultant Colorectal Surgeon during the admission select ‘not seen’.
Was the patient seen by an
IBD Nurse Specialist
during the admission?
This refers to being seen by an IBD Specialist Nurse at any time during the admission. This does not include being
seen by a stoma nurse only.
Yes
No
Source: entry in the continuing care case notes, direct entry in nursing notes or entry in notes commenting that
patient seen by IBD Nurse/GI Nurse
Was the patient transferred
to a specialist
gastroenterology ward?
Answer ‘yes’ to this question if the patient was transferred to a specialist gastroenterology ward at any time during
their admission
Yes
No
You have an additional option to indicate that review by a Consultant Colorectal Surgeon was not required, for
instance if admitted under the direct care of a Consultant Gastroenterologist. To be able to tick ‘Not Required’ on the
audit website you will first need to tick ‘Not Seen’, however we would like to confirm that if this is done the answer will
be considered as ‘Not Required’ during data analysis
A specialist gastroenterology ward is defined for this audit as one where Gastroenterology patients (including liver
disease) are routinely allocated and that have specialist medical, nursing and allied health professional staff. It can be
a medical, surgical or joint specialist ward
Source: From medical, surgical, nursing or therapy records or hospital patient administration records
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.1.7i
If yes to Q 1.1.7, which
type of ward?
If you answered Yes to Q1.1.7 you should indicate which type of specialist gastroenterology ward the patient was
transferred to from the following options:
a) Medical
b) Joint Medical / Surgical
c) Surgical
a) Medical:
A ward in the hospital which predominantly deals with medical gastroenterology
b) Joint Medical / Surgical: A joint medical and surgical gastroenterology ward
c) Surgical:
A ward in the hospital which predominantly deals with surgical gastroenterology
Source: From medical, surgical, nursing or therapy records or hospital patient administration records
1.2
1.2.1
Comorbidity
Did the patient have any
significant comorbid
diseases? (select all that
apply)
a) Heart Disease
b) Peripheral Vascular
Disease
c) Respiratory
d) Renal Failure
e) Diabetes
f) Stroke
g) Liver Disease
h) Active Cancer
i) None
j) Other, please specify
1.3
1.3.1
There only needs to be a mention of these in clerking notes or previous letters, rather than extensive supporting
information, to include as comorbidity. You can choose more than one option.
If you choose ‘other’ please be sure to give further details. Only include ‘other’ if it is a significant comorbidity such as
non-cured cancer (except BCC).
Source: Clerking notes / Patient Letters
Discharge / Mortality
Did the patient die during
admission?
Indicate whether the patient died during the admission
If no you must still answer Q1.3.1iv below
Yes
No
1.3.1i
If yes, Date of death?
Please enter the date of death in the format:
day (DD), month (MM) year (YYYY) = DD/MM/YYYY
__/__/____
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.3.1ii
If yes, Primary cause of
death?
a)
b)
c)
d)
e)
Dementia
Cerebrovascular disease
Heart disease
Respiratory disease
Post operative
complications
f) Renal failure
g) Pulmonary Embolism
h) Liver Disease
i) Gastrointestinal Bleeding
j) Other, please specify
If a post mortem was performed state the primary cause of death indicated on the post mortem report. We provide a
list of options a) to i) based upon the causes of death indicated in previous rounds of the IBD Audit. If none of a) to
i) are appropriate please choose j) ‘Other’ and enter further details, including if no details of the cause of death are
clearly available by stating ‘not known’ in the cause of death box.
If there was no post mortem state the primary cause of death entered on the death certificate counter foil in the
notes.
If neither of the above are available then you can use the last primary diagnosis stated in case notes recorded prior
to, or after death.
Source: patient case notes, death certificate, post mortem report
1.3.1iii
Please use this space to
enter any further details of
death if you feel it is
necessary (max of 300
characters)
This question allows you to elaborate on the details of death where you feel it might be useful and appropriate to do
so using the space provided (there is a max of 300 characters available on the website which includes spaces)
1.3.1iv
If no to 1.3.1, Date of
Discharge
If you answered No to Q 1.3.1 then you must enter the date of discharge from your hospital in the format:
day (DD), month (MM) year (YYYY) DD/MM/YYYY
__/__/____
Source: This will be found on PAS medical or nursing notes
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.3.1v
Was the patient:
a) Discharged home
b) Transferred to another site
for surgery
c) Transferred to another site
for further medical
management
1.4
1.4.1
Please indicate the destination that the patient was discharged to
Source: patient case notes, PAS system
Medication on Admission
What treatment was the
patient taking for Crohn’s
Disease on admission?
(please select all that apply)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
5-ASA
Azathioprine
Mercaptopurine
Methotrexate
Antibiotics
Corticosteriods
Dietary Therapy
Anti-TNF-α
None
Other (e.g. trial medicine)
please specify:
Include only oral drugs and drugs which are used directly for the treatment of Crohn’s Disease:
a) 5-ASA drugs: includes drugs such as Salazopyrine, Balsalazide, Pentasa, Asacol, Olsalazine, Salofalk. Only
record oral 5-ASA
b) Azathioprine
c) Mercaptopurine
d) Methotrexate
e) Antibiotics: Only include those used to treat Crohn’s Disease e.g. Ciprofloxacin or Metronidazole
f) Corticosteroids: Prednisolone or Budesonide. Only record oral steroids
g) Dietary therapy: Modulen, EO28, Esmogen, TPN
h) Anti–TNF: Infliximab or Adalimumab. Include if currently on Adalimumab. Include if having regular Infliximab
infusions (8 weekly or less) or if had Infliximab within the previous 8 weeks. Include if on Thalidomide for treatment
of Crohn’s Disease
j) Other: (eg trial medication) Do not include treatment not specifically for Crohn’s; disease, e.g. treatment for
osteoporosis, vitamin B12, folic acid. Please indicate details of the ‘Other’ treatment in the space provided.
Source: From medical, nursing or therapy records
1.4.2
In the 12 months prior to this
admission was the patient
taking Steroids (at any time)
for >3 months?
1.4.2i
If yes, was an appropriate
dose reduction planned?
Yes
When looking to answer ‘Yes’ or ‘No’ include any dose of corticosteroids (Prednisolone or Budesonide) taken
continuously for more than 3 months for Crohn’s Disease (and not any other indication) during the 12 months prior
to the date of this admission
Source: Medical or nursing notes; Clinic letters
Please answer Yes or No
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.4.2ii
1.4.2iii
1.5
1.5.1
No
Source: Medical or nursing notes; Clinic letters
If yes, was bone protection
used?
Yes
No
Bone protection agents such as calcium, calcium with vitamin D, Bisphosphonates (alendronate, risendronate,
disodium etindronate)
Was a DEXA scan done?
Yes
No
Bone densitometry may be measured by DEXA scan or heel ultrasound.
1.6.1
Source: Medical or nursing notes, clinic letters or radiology or nuclear medicine results section
Smoking Status
What was the smoking
status of the patient?
a) Current smoker
b) Lifelong non-smoker / ex
smoker
c) Not documented
1.6
Source: Medical or nursing notes, Clinic letters
Current smoker - if the patient is either a) currently smoking or b) has given up within the last 3 months
Lifelong non-smoker/ex-smoker - if stopped smoking >3 months ago or never smoked
Not documented - if no documentation of smoking status on this admission
Source: Medical or nursing notes
Patient History
Did the patient have a preadmission diagnosis of
Crohn’s Disease?
Yes / No
If the primary reason for admission was indicated as c) Elective admission for surgery in Q 1.1.2 then you do not
need to answer this question.
If patient had previous diagnosis of Crohn’s Disease based on endoscopic, histological or radiological evidence
and/or began any active treatment for CD (at any time) then class as a pre-admission diagnosis of Crohn’s Disease.
If the patient had been referred by GP (or others) with a possible diagnosis of CD but diagnosis had not been made
then class as ‘no pre-admission diagnosis of CD’
1.6.2
What was the extent of the
disease?
(select all that apply)
a) Terminal ileum (L1)
b) Colonic (L2)
c) Ileo-colonic (L3)
Source: Medical, nursing or therapy records. An established diagnosis of Crohn’s Disease will most often be
recorded in the initial clerking. However you may need to search previous clinic letters
a) Terminal ileum (L1)
b) Colonic (L2) – Evidence of colonic disease by endoscopy or radiology with no evidence of small bowel disease.
c) Ileo-colonic (L3) – Both small bowel and colonic disease
d) Perianal Disease – No evidence of small bowel or colonic disease but with Crohn’s fissures / fistulas / perianal
abscesses
e) Upper GI (L4)
f) Not known –
Only tick this if there is no clearly identifiable extent of disease.
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
1.6.3
1.6.3i
d) Perianal
e) Upper GI (L4)
f) Not known
Has the patient had previous
admissions to your hospital
with Crohn’s Disease in the
two years prior to this
admission?
Yes
No
If yes, how many times in the
2 years prior to this
admission?
Do not include: Gastro-duodenal Crohn’s or Oral Crohn’s patients
Source: From medical, nursing or therapy records or IBD database
Answer ‘Yes’ or ‘No’
Source: From medical, nursing or therapy records or hospital patient administration records.
Count all admissions with the primary diagnosis as Crohn’s Disease in the 2 years prior to the audited admission.
This includes both surgical and medical admissions. Do not include day case/overnight admissions for drug
infusions / transfusions / endoscopy. Do not include admission to other hospitals.
Source: From medical, nursing or therapy records or hospital patient administration records.
Section 2: Assessing the Severity of Crohn’s Disease (with reference to your answer to Q1.1.2, if the patient was either admitted electively for
surgery, or transferred from another site for surgery ignore all of section 2)
2.1
2.1.1
2.1.2
Initial assessment during first full day following admission
Number of liquid stools per
day:
__
Not documented
Not required
General well being:
Well
Mild symptoms
Moderate symptoms
Severe symptoms
Not documented
2.1.3
Abdominal Pain:
None
Present
Not documented
Record the number of liquid / semi-formed stools indicated in the handwritten case notes or clinic letter to GP. Include
all bowel movements regardless of whether only blood or mucus or faecal. Sometimes it can be difficult to find a
precise measure. If it is documented as ‘8-10X a day’, answer with the highest number recorded.
Source: Medical or nursing notes and typed letters
This data item is subjective and can be difficult to decide. There is no pre-defined definition of severity. The scoring
system relates to the modified Harvey Bradshaw index to patient’s description of general well being. If general wellbeing is recorded then define as follows: “Well” = well; “Below par” = mild symptoms; “Poor” = moderate symptoms;
“terrible” = severe symptoms.
If general well-being is not recorded and/or you can’t make value judgement from the clinical details from that clinic
visit, enter “Not Documented”.
Source: Medical or nursing notes and typed letters.
If there is no documented abdominal pain put “Not documented” rather than “None”.
If the severity is not specifically recorded, but abdominal pain is mentioned, you will have to make a judgment on
severity. If you can not make a judgement on the available data in the case notes, put “Not documented”.
Source: Medical or nursing notes and typed letters.
UK IBD Audit, 3rd Round Adult Crohn’s Disease Proforma Help Notes, Updated 06.04.11
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
2.1.4
Abdominal Mass
Dubious = thickened small bowel or colonic loops but not recorded as definite mass.
2.1.5
2.1.6
2.16i
2.16ii
2.16iii
2.2
2.2.1
None
Present
Not documented
Did the patient report any
of the following
complications?
Mouth ulcers – Yes / No / ND
Arthralagia - Yes / No / ND
Pyoderma Gangrenosum Yes / No / ND
Anal fissure - Yes / No / ND
Fistula - Yes / No / ND
Erythema Nodusm - Yes / No
/ ND
Abscess - Yes / No / ND
Iritis - Yes / No / ND
Other, please Specify
What were the admission
results for the following
tests?
CRP mg/L
___
Not documented
HB g/dL
___
Not documented
Albumin g/L
__
Not documented
Source: Medical or nursing notes and typed letters.
Source: Medical or nursing notes and typed letters
Continued overleaf
Record results of blood tests either done at this clinic visit or in the 4 weeks before or after this clinic visit. If multiple
blood tests done in this time then document those done nearest to this clinic visit
Source: Laboratory results section of case notes most likely source. Other sources may be hand written case notes,
clinic letters. If none found then check computerised laboratory results service in your organisation (if one exists)
The initial results for CRP on admission must be between 0 and 800
The initial result for Hb on admission must be between 2.0 and 20.0
The initial result for Albumin on admission must be between 5 and 50
Exclusion of Infection (in patients with diarrhoea as a presenting symptom)
Was a stool sample sent for
Standard Stool Culture?
Record as Yes if a stool sample was sent for standard stool culture if the patient had diarrhoea (i.e. was producing
loose or semi-formed stools)
Do not include for any subsequent episodes of diarrhoea following admission
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Yes / No /NA
2.2.1i
Date sent?
Source: Best source will be microbiology report which should have the date sample received. Also review
PAS/computer records and medical, nursing or therapy records
Record the date that stool culture was sent. If the patient had a stool sample sent within 7 days prior to admission
this can included in this section.
__/__/____
2.2.1ii
Was it positive?
Source: Best source will be microbiology report which should have the date sample received. Also review
PAS/computer records and medical, nursing or therapy records
Answer Yes or No
2.2.1iii
Yes / No
Date of positive sample
Source: Best source will be microbiology report, PAS / computer records or medical, nursing or therapy records
DD / MM / YYYY
Was a stool sample sent for
CDT?
Yes / No / NA
If the patient had diarrhoea (i.e. was producing loose or semi-formed stools) then record if and when the stool sample
was sent. Do not include for any subsequent episodes of diarrhoea following admission.
Record the date that the stool sample was sent. If the patient had a stool sample sent within 7 days prior to
admission this can included in this section.
2.2.2i
Date sent
Source: Best source will be microbiology report which should have the date sample received. Also review
PAS/computer records and medical, nursing or therapy records
DD / MM / YYYY
2.2.2ii
Was it positive?
2.2.2iii
Yes / No
Date of positive sample
2.2.2
Source: Microbiology report / PAS / computer records / medical, nursing or therapy records
DD / MM / YYYY
Source: Microbiology report / PAS / computer records / medical, nursing or therapy records
2.3
Weight assessment and dietetic support during admission
2.3.1i
Was the patient’s weight
measured during
admission?
Yes / No
a) Was BMI measured?
Yes / No
Record if the patient’s weight was recorded at any time during admission. Weight may be recorded in the medical
notes, nursing notes, observation chart or in separate dietetic notes. Body Mass Index is weight (Kg) divided by
height2 (meters).
Source: Dietetic/Medical/Nursing/Therapy notes. If you are not sure where the dietician enters information in the case
report contact your dietetic department. In some hospitals the dietetic records are kept separately from the rest of the
notes
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
2.3.2
2.3.3
Did a dietician see the
patient?
Did a dietician visit the patient at any time during admission?
Yes / No
Source: Dietetic/Medical/Nursing/Therapy notes
Was dietary treatment
initiated?
Any dietary advice or dietary supplements given to the patient. This includes general advice on a diet high in calories,
advice on dietary supplements, specific Crohn’s specific dietary therapy to treat active disease or TPN.
Yes / No
Source: Dietetic/Medical/Nursing/Therapy notes
2.3.3i
2.3.3ii
2.3.4
Was exclusive liquid
enteral nutrition therapy
prescribed?
Yes / No
Was supplemental liquid
enteral nutrition therapy
prescribed?
Yes / No
Was parenteral nutrition
given?
Yes / No
Section 3: Medical Interventions
Discuss with Dietetics Department if unsure
Source: Dietetic/Medical/Nursing/Therapy notes
Discuss with Dietetics Department if unsure
Source: Dietetic/Medical/Nursing/Therapy notes
Includes central or peripheral parenteral nutrition given at any point during admission including after surgery.
Source: Dietetic/Medical/Nursing/Therapy notes
(with reference to your answer to Q1.1.2, if the patient was admitted electively for surgery or transferred from another site
for surgery ignore sections 3.2 and 3.3 (other than Q3.3.2) and 3.4
3.1
Use of anti-thrombotic therapy
3.1.1
Did the patient have a
thrombotic episode during
this admission?
3.1.2
Yes / No
Was the patient given
prophylactic Heparin?
Yes / No
3.2
Steroid Therapy
3.2.1
Were corticosteroids
administered during this
admission?
Source: medical, nursing or therapy records
Any dose of Heparin and can either be fractionated or unfractionated Heparin.
Source: Drug chart, medical, nursing or therapy records
i. Indicate “yes” if IV steroids were used at any time except if given after surgery. Any intravenous corticosteroid
preparation that was used to treat Crohns should be included.
ii. Oral steroids: any orally administered corticosteroid that was used to treat Crohns should be included
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Yes / No
3.2.1i
3.2.2
If yes, which were initially
prescribed
a) IV corticosteroids
b) Oral corticosteroids
Which of the following
steroids were prescribed?
a)
b)
c)
d)
i.
Prednisolone
Budesonide
Hydrocortisone
Methylprednisolone
Initial dose?
(Mg/day)
ii.
What date was the
therapy initiated?
iii.
Was therapy
increased during this
admission? Yes / No
iv.
What date was
therapy increased?
iii. No……Indicate here if either a) no steroids were used or b) no IV or oral steroids were used i.e. steroid enemas or
suppositories.
Source: Drug charts, medical, nursing or therapy records, hospital patient administration records
Only include either oral corticosteroids (Prednisolone or Budesonide) or IV steroids (Hydrocortisone or
Methylprednisolone). Do not include rectal or topical steroids.
i, ii, iii, iv
It can occasionally be difficult to define the dose at initiation or increase. For example, if the 1st doctor prescribed
20mg prednisolone this would be the initial dose and later that day a 2nd doctor increased it to 40mg then this would
be the increased dose. You may need to use your judgment to decide a significant increase in therapy and the dose.
In general, this will be the maximum daily dose in first 72 hours after admission. Record the highest dose prescribed
in the first 48 hours of any steroid (oral or IV) prescription.
If the patient was admitted on steroids and the dose was increased, record the increased dose
Source: Drug charts, medical, nursing or therapy records, hospital patient administration records
3.3
Which other therapies did the patient receive?
3.3.1
Anti-TNF therapy
Yes / No
3.3.2
3.3.3
i) Start Date
ii) Did the patient respond?
Yes / No
Clinical Trial
Yes / No
i) Please specify:
ii) Start date
iii) Did the patient respond?
Yes / No
Significant Other
therapies?
i.
ii.
Record date anti-TNF therapy started (Infliximab or Adalimumab) initiated if applicable to this admission.
Select this if the patient required no further therapies during this admission.
Source: Medical or nursing notes
i.
Please record the name of the clinical trial
ii.
Record the date the clinical trial started with this patient
iii.
Select this if the patient required no further therapies during this admission
Source: Medical or nursing notes
Please include only significant other medical therapies. If the patient underwent surgery at this point, select ‘no’ and
all relevant surgical data will be captured in section 4
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Yes / No
i) Please provide the name of the other therapy provided
i) Please specify
ii) Start Date
iii) Did the patient respond?
Yes / No
Section 4: Surgical Interventions (If you indicated b) transferred to another site for surgery in your answer to Q1.3.1v, ignore all of section 4. Q4.1.1 will
automatically default to ‘No’ on the web tool if that is the case
4.1
Surgical Therapy
4.1.1
Did the patient have surgery
on this admission?
“Yes” includes any operation including minor Perianal surgery.
Answer “No” if only examination under anaesthetic (EUA) was performed without any intervention. Do not include
endoscopic procedures.
Yes / No
4.1.2
4.1.3
4.1.4
4.1.4i
__/__/____
Not known
Source: Medical Notes / Nursing Notes.
Record the date that the initial decision was taken to undertake surgery for Crohn's Disease. This may occasionally
difficult to determine. The date that the decision was made to operate may be prior to the admission date ie in the
outpatient department. Note the date the decision was definitely made to operate rather than “planning”.
If notes state something like ‘if CRP>??, and diarrhoea unchanged in 2 days then will need surgery’ then indicate
date as 2 days from that entry.
What was the date of the
surgery?
Source: Medical case notes
Record date first operation was performed
Use format: day (DD), month (MM) year (YYYY) DD/MM/YYYY
What date was the decision
made to operate made?
__/__/____
Was there a delay of more
than 24 hours between
decision to operate and
surgery for non-elective
patients?
Yes / No
Source: Medical Notes / Nursing Notes.
Compare the dates of 4.1.2 and 4.1.3 to determine if there was a ‘delay’ between the decision being made and the
actual date of the operation. If there was a delay of 24 hours or more then please indicate what the reason for this
delay was.
If yes, what was the reason for
the delay?
a) Improvement in severity of
Crohn’s
b) Cancelled due to lack of
theatre time
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4.1.5
4.1.6
c) Cancelled for other clinical
reasons (e.g. correction of
hypokalaemia)
d) Patient declined surgery or
needed time to consider
e) Other please specify
Was the patient seen by a
stoma nurse during this
admission?
Yes / No
i. If yes, what date was the
patient first seen by a stoma
nurse?
What was the grade of the
senior surgeon present?
a) Consultant Colorectal
b)
c)
d)
e)
f)
g)
4.1.7
Surgeon
Consultant GI Surgeon
(non-colorectal
Consultant General Surgeon
Other Consultant Surgeon
Specialist Registrar
Associate Specialist
Other please specify
Source: Medical case notes, operation notes
Entries from stoma nurse may be in the medical, nursing notes or separate stoma care nursing notes. If you have
difficulty finding this information, contact your stoma nurse (if you have one) and ask.
i.
Enter date first seen by stoma nurse during this admission. Do not include if the patient was seen in the
outpatient department but not during this admission
DD / MM / YYYY
Source: Medical notes/Nursing notes
The operation notes should include details of all those present at the operation. Please indicate who was the most
senior member of staff that was present at the operation, they may not have necessarily performed or led on the
operation.
Consultant Colorectal surgeon: a surgeon who has a specialist interest in colorectal surgery and is a member of
ACPGBI
Consultant GI surgeon (non-colorectal): a GI surgeon with a non-colorectal specialty interest e.g. upper GI or
hepato-biliary-pancreatic surgery
Consultant General Surgeon: a surgeon with general rather than specialist interest
Other Surgical Consultant: a surgeon with a specialist interest which is non-GI e.g. vascular surgeon, breast
surgeon, gynaecologist, transplant surgeon
Associate Specialist:
Specialist registrar: includes research registrar
Other: state which grade e.g. F2, staff grade, associate specialist
What were the indications for
surgery? (Select all that apply)
Source: Medical notes, operation note, nursing or anaesthetic notes. If you are unsure about which grade of
surgeon performed the surgery contact your surgical colleagues who may be able to help you.
Record the primary indication(s) for surgery prior to operation. In some cases there may be multiple indications,
for example perforation and abscess drainage.
a)
b)
c)
d)
Failure of medical therapy: Failure of any type of medical therapy and surgery performed because of continued
symptoms. Do not grade as failure of medical therapy if any more specific indication is present
Toxic megacolon: transverse colon >5.5cm on X-ray (plain abdominal X-ray or CT scan)
Bleeding: if primary indication was to stop uncontrolled or continued bleeding.
Failure of Medical Therapy
Toxic megacolon
Bleeding
Obstruction
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e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
Completion protectomy
High Grade Dysplasia
Low Grade Dysplasia
Ungraded Dysplasia
Cancer
Perforation
Abscess
Formation of ileostomy
Closure of stoma
Other indication please
specify, please specify
Obstruction: If preoperative symptoms or radiology suggested significant obstruction
Completion proctectomy: Record as completion proctectomy if this was the primary reason cited for the operation.
High Grade, Low Grade, Ungraded Dysplasia: Record as dysplasia/cancer if planned surgery where there was
known to be colonic dysplasia or cancer. Do not include if found after surgery.
Cancer: Record if dysplasia or cancer from pre-operative histology.
Perforation: Record as perforation if known to have a perforation pre-operatively
Abscess: Include intra-abdominal abscess, perineal abscess, ischio-rectal abscess.
Continued overleaf
Formation of ileostomy: Record as formation of ileostomy if this was the primary reason cited for the operation.
Closure of stoma: Record as closure of stoma if this was the primary reason cited for the operation.
Other: try and keep to the above indications wherever possible. If there is an exceptional indication please state
what this is.
Source: The primary indication for surgery will usually be recorded in the operation note. If it is not recorded there
you may have to infer the indication from preceding entries in medical notes or the results of investigation (e.g.
radiology showing abscess or perforation)
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4.1.8
Type of intervention (select all
that apply)
a) Segmental / extended
colectomy
b) Subtotal colectomy
c) Protocolectomy
d) Stricturoplasty
e) Ileal / Jejunal Resection
f) Resection of intraabdominal fistula
g) Proctectomy
h) Completion proctectomy
i) Ileocolonic resection
j) Drainage of abscess
k) Formation of ileostomy or
colostomy
l) Revision of stoma
m) Perineal procedure
n) Closure of stoma
o) Division of adhesions
p) Other intervention, please
specify
4.1.8i
Was the surgery done
laparoscopically /
laparoscopically-assisted?
Yes / No
Try to keep to the listed broad interventions wherever possible.
If there was a major intervention (e.g. colectomy) together with a minor intervention, only record the major
intervention.
If there is an exceptional indication not included in this list please state what this is.
Indicate ‘yes’ if surgery was completed laparoscopically or laparoscopically-assisted. This will be indicated in the
operation notes. If the operation was started laparoscopically but required to be converted to an open operation
answer ‘No’
Source: If you are unsure about which type of operation was performed contact your surgical colleagues
4.1.9
Was the ASA status recorded
pre-operatively?
Yes / No
If yes, what was the ASA
Status?
1 / 2 / 3 / 4 / 5 / N/A
4.2
ASA is the American Society of Anaesthesiologists (ASA) grade that is widely used as a predictor of operative
mortality. This information should be recorded in the anaesthetic records that are usually in a separate part of the
case notes. It may be entered in the medical hand written case notes prior to surgery.
The ASA status can be difficult to find. If you are not familiar with surgical or anaesthetic notes please contact your
anaesthetics department who should be able to tell you where this information is documented.
Source: Anaesthetic notes. Possibly in operation or medical notes
Surgical Complications
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
4.2.1
Did the patient suffer from any
of these complications
following their surgery?
(select all that apply)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
Wound Infection
Rectal stump complications
Intra-abdominal bleeding
Intra-abdominal sepsis
Anastomotic leakage
Stoma complications
Deep vein thrombosis (DVT)
Pulmonary embolus (PE)
Ileus requiring TPN
Cardiac
Respiratory
Clostridium difficileassociated diarrhea (CDAD)
m) Other, please specify
No complications
Wound Infection
This is defined as one or more of the following: evidence of purulent discharge from wound, wound infection
requiring additional antibiotic therapy, and/or requires further surgery
Rectal stump complications
For example continued bleeding per rectum which requires additional medical therapy or further surgery on that
admission or dehiscence of rectal stump
Intra-abdominal bleeding: Confirmed by imaging and/or requiring angiogram or further surgery.
Intra-abdominal sepsis: Confirmed by imaging (ultrasound, CT or MRI scan) and/or requiring either surgical or
radiological drainage
Anastomotic leakage: Evidence of leakage of luminal contents in surgical drain, collection of fluid around
anastomosis either by radiology or further surgery on that admission
Stoma complications: These will include ischaemia, retraction or separation of stoma, peristomal fistula or high
output stoma (defined as requiring additional IV fluids more than one week after surgery). Only include this as a high
output stoma if this is the primary reason for continuing IV fluids
Deep vein thrombosis (DVT): Confirmed by ultrasound, CT or other imaging modality
Pulmonary embolus (PE): Confirmed by V/Q scan or CT pulmonary angiography or pulmonary angiography
Ileus requiring TPN: Record if prolonged ileus after surgery such that PN was initiated to provide nutrition or PN
was continued which had been started prior to surgery
Cardiac: Myocardial infarction (raised troponin T, or troponin I), congestive cardiac failure (clinical or radiological
evidence)
Respiratory: Defined as symptomatic chest infection/pneumonia requiring additional antibiotic therapy
Clostridium difficile-associated diarrhoea (CDAD): Select if the patient presented with CDiff related diarrhoea
following surgery when there was no indication of the infection prior to surgery
4.3
Post-Operative Prophylactic Therapy
4.3.1
Was the patient prescribed
any of the following drugs on
discharge? (please select all
that apply)
Record any of these drugs that were started or continued after surgery.
a)
b)
c)
d)
e)
f)
g)
h)
Continued overleaf
Azathioprine
Mercaptopurine
Metronidazole
5-ASA
Methotrexate
Infliximbab
Other please specify
None
5-ASA drugs include: Salazopyrine, Balsalazide, Pentasa, Asacol, Olsalazine, Salofalk
Source: Discharge summary / medical or nursing notes / drug chart
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
Section 5: Discharge Arrangements (If the patient died during the admission or you indicated either b) transferred to another site for surgery or c)
transferred to another site for further medical management in your answer to Q1.3.1v ignore all of section 5
5.1
Discharge Arrangements
5.1.1
Was the patient taking oral
steroids on discharge?
Yes / No / N/A
Was a steroid reduction
programme started on
discharge?
Yes / No / N/A
Were bone protection
agents prescribed?
Yes / No / N/A
5.1.1i
5.1.1ii
5.1.2
5.1.3
Was patient on
immunosuppressive on
discharge?
Yes / No / N/A
Was there a plan for
maintenance Anti TNF on
discharge?
Yes / No / N/A
Record whether the patient was taking oral steroids when discharged.
Source: Discharge summary, drugs on discharge note to GP, medical or nursing notes, patient administration system
The reduction programme should be documented either in the discharge summary or in a copy of the letter sent to the
patient’s GP.
Source: Discharge summary, drugs on discharge note to GP, medical or nursing notes, patient administration system
Bone protection agents such as calcium, calcium with vitamin D, Bisphosphonates (Alendronate, Risendronate,
Disodium Etindronate)
Source: Discharge summary; Discharge letter to the GP; Medical or nursing notes
Record whether the patient was taking Azathioprine on discharge.
Source: Discharge summary, drugs on discharge note to GP, medical / nursing notes, patient administration system
The maintenance programme should be documented either in the discharge summary or in a copy of the letter sent to
the patient’s GP.
Source: Discharge summary, drugs on discharge note to GP, medical or nursing notes, patient administration system
Section 6: Outpatient Visits
6.1
6.1.1
6.1.2
Patient History
Did the patient have
previous outpatient visits for
Crohn’s Disease at this
hospital in the 12 months?
Yes / No*
* If no, you do not need to
answer any further questions
in this section
How many times was the
patient reviewed for their
Crohn’s Disease in an
outpatient’s clinic in the 12
This only includes previous outpatient visits in your Trust / Health Board. Do not include outpatient visits to other
organisations for management of Crohn’s.
Continued overleaf
Source: From medical, nursing or therapy records or hospital patient admin records.
Include all recorded OPD visits (for the management of Crohn’s Disease) over 12 months. Do not include day cases
(eg endoscopy, blood transfusions and drug infusions) or OPD visits for other reasons. Do not include outpatient
visits to other hospital trusts for Crohn’s Disease.
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UK IBD Audit 3rd Round – Adult Crohn’s Disease Help Notes
6.1.3
6.1.4
months prior to the start
date of this admission?
__
Approximately how many
times was the patient seen
by the following staff in the
12 months prior to the start
date of this admission? (If
the patient was seen by more
than one of the following staff
in a single clinic visit please
count each staff member
individually)
i.
Consultant
ii.
IBD Nurse Specialist
iii.
Specialist Registrar
iv.
F2 (SHO)
What was the date of the last
visit at the Outpatient
Department prior to
admission?
The number of visits must be between 1 and 20
Source: The most appropriate data source will be PAS. Alternatively, hand-written case notes and typed letters.
The patient may have been seen by more than one health care professional in a single visit and it is important to
record all of these contacts.
You will need to check typed letters/handwritten notes for mention of ‘seen by…’ or ‘discussed with…’
Source: Medical / nursing / clinic notes
This is the last documented OPD visit for Crohn’s Disease prior to admission. If the last visit was the one which
initiated the inpatient admission being audited in sections 1 to 5 please ignore it and use the previous one.
Source: Medical / nursing / clinic notes
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