UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
Help Notes for Adult Ulcerative Colitis (Inpatients)

Patient Identification. Patients should be included if they have a primary discharge diagnosis of Ulcerative Colitis that matches the ICD-Codes provided.
We know that there are often difficulties in case identification 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 Ulcerative Colitis
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 (ie
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
Number
Patient Demographics
A
B
C
D
Auditor Discipline:
a) Consultant
b) Other medical staff
c) Nurse
d) Manager
e) Clinical Audit
f) Other, please specify:
Patient Audit Number:
What was the patient’s age
at admission?
Gender:
Male / Female
Help Notes
Please enter the discipline of any individual who made a significant contribution to the data collection and entry.
This is automatically generated when you start to enter a new case onto the IBD Audit data entry website. 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.
Enter the age of the patient at the date of the admission to hospital.
Indicate Male or female
Section 1: Admission / Mortality
1.1
Admission
1.1.1
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)
Only enter details of one admission per patient even if they were admitted more than once during the audit period,
please audit the admission closest to 1st September 2010.
Source: PAS / medical or nursing notes
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
1.1.2
1.1.3
What was the primary
reason for admission?
a) Emergency admission
for active UC
b) Planned admission for
active UC
c) Elective admission for
surgery
d) New diagnosis of UC
e) Transferred from another
hospital for surgery
f) Transferred from another
site for further medical
management
Which specialty was
responsible for the
patient's care 24 hours
after admission?
a) Acute Medicine
b) Paediatric
Gastroenterology
c) Paediatric Surgery
d) General paediatrics
within a paediatric GI
network
e) Adult Gastroenterology
f) Colorectal Surgery
g) General paediatrics
h) Other, please specify:
a) Emergency admission for active UC: acute admission from GP/A&E/other hospital
b) Planned admission for active UC: patient seen as an outpatient or by GP and admission arranged by hospital
c) Elective admission for surgery: surgery planned prior to the admission
*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 and 3.3.3
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: 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 Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
1.1.4
What date was the patient
first seen by a Consultant
Paediatric
Gastroenterologist?
Enter the date when the patient was first seen by a Consultant Paediatric 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…’
If the patient was not seen by a Consultant Paediatric Gastroenterologist during the admission enter ‘not seen’.
__/__/____
Not seen / Not required
1.1.5
What date was the patient
first seen by a Consultant
Paediatric Surgeon?
__/__/____
Not seen / Not required
1.1.6
1.1.7
Was the patient seen by a
Paediatric IBD Nurse
Specialist during the
admission?
Yes / No
Was the patient transferred
to a specialist
gastroenterology ward?
Yes / No
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 Paediatric Surgeon for planned surgery. To be able to tick ‘Not
Required’ on the audit website you will need to tick ‘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 Paediatric 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…’
If the patient was not seen by a Consultant Paediatric Surgeon select ‘not seen’
You have an additional option to indicate that review by a Consultant Paediatric Surgeon was not required, for
instance if admitted under the direct care of a Consultant Paediatric Gastroenterologist. To be able to tick ‘Not
Required’ on the audit web tool 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
This refers to being seen by a Paediatric IBD Specialist Nurse at any time during the admission. This does not include
being seen by a stoma nurse only.
Source: entry in the case notes, direct entry in nursing notes or entry in notes commenting that patient seen by IBD
Nurse / GI Nurse
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: medical, surgical, nursing or therapy records or hospital patient administration records
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
1.1.7i
If yes which type of ward?
a) Medical
b) Joint Medical / Surgical
c) Surgical
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: 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: medical, surgical, nursing or therapy records or hospital patient administration records
1.2
1.2.1
1.3
1.3.1
Comorbidity
Did the patient have any
significant comorbid
diseases?
(select all that apply)
a) Respiratory
b) Stroke
c) Liver Disease
d) None
e) Other, please specify:
There only needs to be a mention of these in clerking notes or previous letters, rather than extensive supporting
information, to include as a 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?
Yes / No
Indicate whether the patient died during the admission.
1.3.1i
If yes Date of death?
__/__/____
Please enter the date of death in the format:
day (DD), month (MM) year (YYYY)
1.3.1ii
If yes, please write the
primary cause of death in
the box below:
(appears as question 1.3.1iii
on the web tool)
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 on the website which includes spaces).
If you select ‘No’, you must still answer Q1.3.1iv below (date of discharge)
If a post mortem was performed state the primary cause of death indicated on the post mortem report. If no details of
the cause of death are clearly available then state ‘not known’ in the text 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, post mortem report, death certificate
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
1.3.1iv
If no to Q1.1.1, please enter
the date of discharge
__/__/____
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
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
Please indicate the location to which the patient was discharged upon leaving your site
Source: PAS / patient case notes
Section 2: Assessing the Severity of Ulcerative Colitis (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
Patient History
Did the patient have a preadmission diagnosis of
Ulcerative Colitis?
Yes / No
If the primary reason for admission was indicated as ‘c) elective admission for surgery’ in Q1.1.2 then you do not
need to answer this question
If the patient had a previous diagnosis for UC and/or began active treatment for UC (at any time) then class this as a
pre-admission diagnosis of UC.
If the patient had been referred by GP (or other) with a possible diagnosis of UC but diagnosis had not been made,
class this as ‘No’ pre-admission diagnosis of UC.
2.1.2
What was the extent of the
colitis?
a) Proctitis (E1)
b) Left sided (E2)
c) Extensive (E3)
d) Pan Colitis (E4)
e) Unknown
2.1.3
Has the patient had previous
admissions for UC in the two
years prior to this admission?
Yes / No
Source: Medical, nursing or therapy records. A established diagnosis of UC will often be recorded in initial clerking
notes, however you may nee to search previous clinic letters
a) Proctitis – involvement limited to the rectum
b) Left-Sided – Involvement of the descending colon, which runs along the patients left side, up to the splenic
flexure and the beginning of the transverse colon
c) Extensive – Inflammation extending beyond the reach of enemas
d) Pan Colitis – involvement of the entire colon, extending from the rectum to the caecum, beyond which the small
intestine begins
e) Unknown – only select this if there is no clearly identifiable extent of disease
Source: medical, nursing or therapy records / IBD database
Source: patient case notes / PAS
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
2.1.3i
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.3
If yes, how many times in the
two years prior to this
admission?
The number of the admissions must be between 1 and 20, if there have been more than 20 admissions please
contact us to request entry of a number greater than 20.
Severity of Disease
How many loose or bloody
stools were passed in the first
full day following admission>
Not applicable, patient had
stoma / Not documented
What was the highest
recorded pulse rate during the
first full day following
admission?
BPM / Not documented
What was the highest
temperature recorded during
the first full day following
admission?
oC / Not documented
Was a stool sample sent for
Standard Stool Culture?
Yes / No / N/A
If yes,
i. Date sent
ii. Was it positive? Yes / No
iii. If positive, date of positive
sample
Was a stool sample sent for
CDT?
Yes / No / N/A
If yes,
i. Date sent
ii. Was it positive? Yes / No
iii. If positive, Date of positive
Sample
Record the number of liquid / semi-formed stools recorded, include all bowel movements regardless of whether only
faecal, blood or mucous. Sometimes it can be difficult to find a precise measure, if it is documented as 8-10X/day
answer with the highest number recorded. The number entered must be between 0 and 30
Source: medical or nursing notes / stool chart
The value entered must be between 30 and 200 beats per minute (bpm)
Source: patient case notes / patient observation charts
The value entered must be between 34.0 and 42.0, to enter values outside of this range please contact us
Source: patient case notes / patient observation charts
Record as ‘Yes’ if a stool sample was sent for standard stool culture, if the patient had diarrhoea
Source: best source will often be microbiology report which should have dates recorded. Also review PAS and
medical, nursing and therapy records
Record as ‘Yes’ if a stool sample was sent for CDT, if the patient had diarrhoea
Source: best source will often be microbiology report which should have dates recorded. Also review PAS and
medical, nursing and therapy records
Monitoring of Colitis - Radiology
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
2.3.1
Was a plain abdominal x-ray
performed?
Yes / No
If yes,
i. Date requested
ii. Date performed
iii. Date reported by Radiologist
2.3.2
If yes to 2.3.1, was toxic
megacolon present in the xray?
Yes / No / N/A
2.3.2i
Was a repeat x-ray, CT Scan
or MRI Scan performed?
Yes / No
2.3.2ii
If yes, date performed
Section 3: Medical Interventions
Dates are to be entered in the format DD/MM/YYYY
Source: patient case notes (investigations section) / electronic investigation requesting systems / X-Ray report
Dates are to be entered in the format DD/MM/YYYY
Source: patient case notes (investigations section) / electronic investigation requesting systems / X-Ray report
(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, 3.3 (other than Q3.3.3) and 3.4)
3.1
Use of Anti-thrombotic therapy
3.1.1
Did the patient have a
thrombotic episode during
this admission?
Yes / No
Was the patient given
prophylactic heparin?
Yes / No
3.1.2
3.2.
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
Steroid Therapy
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
3.2.1
3.2.1i
3.2.2
Were corticosteroids
prescribed during this
admission?
Yes / No
Indicate “Yes” if IV steroids were used at any time except if given after surgery. Any intravenous corticosteroid
preparation that was used to treat UC should be included.
If yes, which were initially
prescribed?
a) IV corticosteriods were
prescribed
b) Oral corticosteroids were
prescribed
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.
Which of the following
steroids were initially
prescribed?
a) Prednisolone
b) Methylprednisolone
c) Budesonide
d) Hydrocortisone
Only include either oral corticosteroids (Prednisolone or Budesonide) or IV steroids (Hydrocortisone or
Methylprednisolone).
Do not include rectal or topical steroids.
i. Initial dose? (Mg/day)
ii. What date was therapy
initiated?
iii. Was therapy increased
during this admission?
Yes / No. If yes,
iv. What date was therapy
increased?
Oral steroids: any orally administered corticosteroid that was used to treat UC should be included
Source: Drug charts, medical, nursing or therapy records, hospital patient administration records
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
If ‘Yes’ is selected, questions in section 3.3 do not need to be completed – go straight to section 3.4 – response to
treatment
3.2.3
Did the patient respond to
corticosteroids and not
require any other significant
therapy for UC?
Yes / No
3.3
Which other therapies did the patient receive?
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
3.3.1
3.3.2
3.3.3
3.3.4
Ciclosporin
Yes / No
i. Start Date
ii. Did the patient respond?
Yes / No
Anti-TNF
Yes / No
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 therapy
Yes / No
If ‘Yes’ selected
i.
Record date Ciclosporin therapy started if applicable to this admission.
ii.
Select this if the patient required no further therapies during this admission.
i. Please specify
ii. Start Date
iii. Did the patient respond? Yes
/ No
i. Please specify the name of the ‘other therapy’ initiated
ii. Please record the start date of this therapy
iii. Answer ‘Yes’ if the patient did not require any further therapy
Source: medication chart / medical or nursing notes
If ‘Yes’ selected
i.
Record date anti-TNF therapy started (Infliximab or Adalimumab) if applicable to this admission.
ii.
Select this if the patient required no further therapies during this admission.
Source: Medication chart / medical or nursing notes
If ‘Yes’ selected
i. Please record the name of the clinical trial
ii. Record 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 case 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.
Source: medical or nursing case notes
3.4
3.4.1
3.4.2
3.4.3
Response to Treatment
Day 1
PUCAI Score =
Not documented
Not applicable
Day 3
PUCAI Score =
Not documented
Not applicable
Day 5
PUCAI Score =
Not documented
Not applicable
PUCAI Score is calculated using the following information:
1. Abdominal pain: No Pain (0) / Pain can be ignored (5) / Pain cannot be ignored (10)
2. Rectal Bleeding: None (0) / Small amount only, in less than 50% of stools (10) / Small amount with most
stools (20) / Large amount >50% of stool content (30)
3. Stool consistency of most stools: Formed (0) / Partially formed (5) / Completely unformed (10)
4. Number of stools per 24 hours: 0-2 (0) / 3-5 (5) / 6-8 (10) / >8 (15)
5. Nocturnal stools (any episode causing wakening): No (0) / Yes (10)
6. Activity level: No limitation of activity (0) / Occasional limitation of activity (5) / Severe restricted
activity (10)
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
3.4.4
At discharge
PUCAI Score =
Not documented
Not applicable
You are able to enter a score within the range of 0-85 where:



Greater than or equal to 65 is severe
35-60 is moderate; 10-30 mild
<10 equals remission
If the patient was discharged within 24hours, please exclude this patient and audit the next applicable
patient. If the patient was discharged following ‘Day 2’ please select ‘Not applicable-patient discharged’
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 this is the case)
4.1
Surgical Therapy
4.1.1
Did the patient have surgery
on this admission?
Yes / No
4.1.2
What date was the decision
made to operate?
__/__/____
Not known
4.1.3
What was the date of the
surgery?
__/__/____
“Yes” includes any operation including minor perianal surgery.
Answer “No” if only examination under anaesthetic was performed without any intervention. Do not include
endoscopic procedures.
Source: Medical Notes / Nursing Notes / Operation Note
Record the date that the initial decision was taken to undertake surgery for UC. This may be occasionally difficult to
identify. 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.
Source: Medical case notes
Record date first operation was performed Use format: day (DD), month (MM) year (YY)
Source: Medical Notes / Nursing Notes / Operation Note / Theatre system
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
4.1.4
4.1.5
Was there a delay of more
than 24 hours between
decision to operate and
surgery for non-elective
patients?
Yes / No
i. If yes, what was the reason
for the delay?
a) Improvement in severity of
UC
b) Cancelled due to lack of
theatre time
c) Cancelled for other clinical
reasons (eg 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
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.
Source: Medical or nursing notes / Theatre system
Entries from stoma nurses may be in the medical or 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. Do not include if the patient was
seen by the stoma nurse during an outpatient appointment – only if they were seen during the hospital admission
i. Enter date first seen by stoma nurse during this admission: DD/MM/YYYY
i. If yes, what date was the
patient first seen by a stoma
nurse?
Source: Medical, nursing or stoma nurse notes
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
4.1.6
4.1.7
What was the grade of the
senior surgeon present?
a) Consultant Paediatric
Surgeon
b) Consultant Colorectal
Surgeon
c) Consultant GI Surgeon (non
colorectal)
d) Consultant General Surgeon
e) Other Consultant Surgeon
f) Specialist Registrar
g) Other, please specify:
What were the indications for
surgery?
(Select all that apply)
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)
Failure of Medical Therapy
Toxic megacolon
Bleeding
Obstruction
Completion proctectomy
High Grade Dysplasia
Low Grade Dysplasia
Ungraded Dysplasia
Cancer
Perforation
Abscess
Formation ileostomy
Closure of stoma
Other indication, please
specify:
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.
If you are unsure about which grade of surgeon performed the surgery contact your surgical colleagues who may be
able to help you
Source: Medical notes, operation note, nursing or anaesthetic notes
Record the primary indication(s) for surgery prior to operation. In some cases there may be multiple indications, for
example perforation and abscess drainage.
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.
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.
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 to keep to the above indications wherever possible. If there is an exceptional indication please state what
this is
Source: Medical or nursing notes / Operation Note / Investigation reports
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
4.1.8
4.1.9
Type of intervention
(select all that apply)
a) Subtotal colectomy
b) Protocolectomy
c) Proctectomy
d) Ileoanal pouch with stoma
e) Ileoanal pouch without
stoma
f) Formation of ileostomy
g) Other, please specify:
i. Was the surgery done
laparoscopically /
laparoscopically-assisted?
Yes / No
Was the ASA status recorded
pre-operatively?
Yes / No
i. If yes, what was the Status?
1 / 2 / 3/ / 4/ / 5 / NA
Try and keep to the listed 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’. If you are unsure about which type of operation was performed contact your surgical colleagues
Source: Medical notes / Operation Note / Theatre system
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
anaesthetic department who should be able to tell you where this information is documented.
Source: Anaesthetic notes. Possibly in operation or medical notes
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
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UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
4.2
Surgical Complications
4.2.1
Did the patient suffer from
any of these complications
following their surgery?
(select all that apply)
Section
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
a) Wound infection
b) Rectal stump complications
radiological drainage
Anastomotic leakage: Evidence of leakage of luminal contents in surgical drain, collection of fluid around
c) Intra-abdominal bleeding
d) Intra-abdominal sepsis
anastomosis either by radiology or further surgery on that admission
Stoma complications:
e) Anastomotic leakage
f) Stoma complications
These will include ischaemia, retraction or separation of stoma, peristomal fistula or high output stoma (defined as
g) Deep vein thrombosis (DVT) requiring additional IV fluids more than one week after surgery). Only include this as a high output stoma if this is the
h) Pulmonary embolus (PE)
primary reason for continuing IV fluids
Deep vein thrombosis (DVT): Confirmed by ultrasound, CT or other imaging modality
i) Ileus requiring TPN
Pulmonary embolus (PE): Confirmed by V/Q scan or CT pulmonary angiography or pulmonary angiography
j) Small bowel obstruction
Ileus requiring TPN: Record if prolonged ileus after surgery such that PN was initiated to provide nutrition or PN was
k) Cardiac
l) Respiratory
continued which had been started prior to surgery
Cardiac: Myocardial infarction (raised troponin T, or troponin I), congestive cardiac failure (clinical or radiological
m) Clostridium difficileassociated diarrhea (CDAD) evidence)
Respiratory: Defined as symptomatic chest infection/pneumonia requiring additional antibiotic therapy
n) No complications
Clostridium difficile-associated diarrhoea (CDAD): Select if the patient presented with CDiff related diarrhoea
o) Other, please specify:
following surgery when there was no indication of the infection prior to surgery
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
5.1.2
5.1.3
Record whether the patient was taking oral steroids when discharged.
Source: Discharge summary / drugs on discharge note to GP / medical or nursing notes / PAS
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 / PAS
Bone protection agents such as calcium, calcium with vitamin D, Bisphosphonates (Alendronate, Risendronate,
Disodium Etindronate)
Source: Discharge summary / drugs on discharge note to GP / medical or nursing notes / PAS
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
Copyright Royal College of Physicians, London
14
UK IBD Audit 3rd Round – Adult Ulcerative Colitis Help Notes
5.1.4
5.1.4i
5.1.5
Was the patient on
immunosupressives on
discharge?
Yes / No / N/A
If yes to 5.1.4, please indicate
which immunosupressives
a) Ciclosporin
b) Methotrexate
c) 6MP
d) Azathioprine
e) Other, please state:
Was there a plan for
maintenance Anti TNF on
discharge?
Yes / No / N/A
Record whether the patient was taking Azathioprine on discharge.
Source: Discharge summary / drugs on discharge note to GP / medical or nursing notes / PAS
The discharge summary or note to GP should contain a list of medications the patient was prescribed upon discharge
Source: Discharge summary / discharge note to GP / medical or nursing notes / PAS
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 / PAS
UK IBD Audit, 3rd Round Adult Ulcerative Colitis Proforma Help Notes, Updated 05.07.11
Copyright Royal College of Physicians, London
15