General Hospital Demographics
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UK IBD Audit 2006 Executive Summary of the National Results for the Organisation & Process of IBD Care in the UK Prepared on behalf of The UK IBD Audit Steering Group by • Association of Coloproctology of Great Britain and Ireland • British Society of Gastroenterology • Clinical Effectiveness & Evaluation Unit, Royal College of Physicians of London • National Association of Colitis and Crohn’s Disease February 2007 REPORT PREPARED BY: Dr Keith Leiper Consultant Gastroenterologist, Royal Liverpool University Hospital & Clinical Director for the UK IBD Audit Mr Derek Lowe Medical Statistician, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Mr Richard Driscoll Director, National Association for Colitis and Crohn’s Disease (NACC) Miss Asha Senapati Consultant Surgeon, Queen Alexandra Hospital, Portsmouth Professor Jonathan Rhodes Professor of Medicine, University of Liverpool Mr Calvin Down IBD Audit Project Manager, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Miss Nancy Pursey IBD Audit Project Co-ordinator, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians ACKNOWLEDGEMENTS The Royal College of Physicians of London and the UK IBD Audit Steering Group (Appendix 1) thank and acknowledge all who have participated in the piloting and development of the audit since the beginning of the Project. The web based data collection tool was developed by Netsolving Ltd. Thanks are due to the many people who have participated in the UK IBD Audit 2006. It is recognised that this has involved many individuals spending time over and above an already heavy workload with no financial recompense. Thanks are also due to • The Health Foundation who fund the UK IBD Audit • The Association of Coloproctology of Great Britain and Ireland • The British Society of Gastroenterology • The National Association for Colitis and Crohn’s Disease (NACC) • All those who contributed to organising the collection, retrieval and input of data including audit, IT and coding staff in addition to the members of the clinical teams. UK IBD Audit 2006 Report CONTENTS Page Executive summary 5 Introduction 15 Aims of the Audit 15 Availability of this report in the public domain 15 Methods 16 Standards in the audit 16 Data collection tool 16 Definition of a ‘site’ 16 Recruitment 16 Selection criteria for the patient cohorts (ICD-10 codes) 17 Data reliability 17 Presentation of results 18 RESULTS Section 1. Key National Results for England, Northern Ireland, 19 Scotland and Wales Organisation and Structure 19 Ulcerative Colitis Inpatients 20 Crohn’s Disease (inpatients & outpatients) 21 Section 2. Organisation and Structure of IBD services as at 1st June 23 2006 General Hospital Demographics 23 Inpatient activity 24 Gastroenterology services 24 Colorectal services 26 Multi-disciplinary working 26 Dietetics & Nutritional services 27 Outpatient services 28 Patient information 28 Monitoring of established immunosuppressive therapy 29 IBD support services 29 Management of Ulcerative Colitis 29 Interactions between hospital and patients and patient groups 30 Section 3. Clinical Audit: Ulcerative Colitis (Inpatient) 31 Patient demographics 31 Admission 32 Co-morbidity 33 Inpatient mortality 33 Mortality after discharge 33 Length of stay 34 Assessment: patient history 34 Assessment: severity of disease 35 Assessment: endoscopic assessment 36 Monitoring of Colitis post admission – general information 37 Monitoring of Colitis post admission – radiology 39 Medical intervention – steroid therapy 40 Medical intervention – other therapies 41 UK IBD Audit 2006 Report Medical intervention - initiating ciclosporin therapy 42 Medical intervention – monitoring ciclosporin therapy 43 Surgical intervention 44 Surgical complications 46 Discharge arrangements 46 Section 4. Clinical Audit: Crohn’s Disease (Inpatient) 48 Patient demographics 48 Admission 48 Admitting speciality 49 Inpatient mortality 50 Mortality after discharge 50 Length of stay 51 Co-morbidity 51 Medication on admission 51 Smoking status 52 Patient history 52 Assessment: severity of disease 53 Assessment: exclusion of infection 54 Assessment: documentation of sepsis 54 Assessment: imaging 55 Assessment: weight assessment & dietetic support 56 Assessment: use of anti-thrombotic therapies 57 Medical intervention - steroid therapy 57 Medical intervention – blood transfusion 57 Medical intervention – treatment initiation with anti-TNF during admission 58 Surgical intervention 58 Post-operative prophylactic therapy 60 Discharge arrangements 61 5. Clinical Audit: Crohn’s Disease (Outpatient) 62 Patient history 62 Assessment of Crohn’s activity 63 Smoking status 64 Monitoring of immunosuppressive therapy 64 Use of corticosteroids 65 Use of anti-TNF therapy 66 Appendices 1. Membership of the UK IBD Audit 2006 Steering Group 67 2. Copies of Audit Proformas 69 3. Pilot sites 92 4. List of hospitals that submitted data to the audit 93 5. List of hospitals that did not submit data to the audit 96 6. UK IBD Steering Group list of IBD Standards 97 UK IBD Audit 2006 Executive Summary Background The UK IBD Audit is the first UK-wide audit performed within gastroenterology. The 1st Round of the UK Inflammatory Bowel Disease Audit was conducted from September 2006 to December 2006. National audit data could support the self assessment requirements of the Healthcare Commission. Although ignored by the National Service Framework program, gastroenterological conditions are common and after cardiac and respiratory disease are the third most common reason for acute medical emergency admissions. IBD includes Crohn’s Disease and Ulcerative Colitis, different disorders, but with considerable overlap in terms of health service care. Together, they affect about 1 in 400 of the population. They present in late adolescence or early adult life so typically affect people who are trying to earn a living and/or raise a family. IBD accounts for 0.3% of absences from work in the UK with an estimated loss of £115 million in productivity per year. At least 80% of Crohn’s disease patients need surgery at some time, as do 25% of patients with ulcerative colitis. There are about 27,000 admissions per year for exacerbations of IBD and admissions are associated with significant mortality. Many deaths occur around the time of surgery and data indicates that young people are disproportionately represented amongst those deaths. Data from individual hospitals has shown a marked variation in mortality rates across the UK. The UK IBD Audit seeks to improve the quality and safety of care for IBD patients in hospitals throughout the UK by auditing individual patient care, service resources and organisation against national standards. The British Society of Gastroenterology has recently published national evidence based guidelines that cover all the clinical aspects of management of IBD. Audit Aims 1. Assess the current structure and organisation of care for those patients with IBD 2. Assess the processes and outcomes of care delivery (inpatient and outpatient) in IBD 3. Enable Trusts to compare their performance and quality of care against national standards 4. Identify resource and organisational factors that may account for variations in care 5. Facilitate, develop and institute an intervention strategy to improve quality of patient care. 6. Repeat the audit to prove that change has occurred 7. Establish measures that healthcare services can use beyond the study to compare quality of IBD services 8. Develop a sustainability programme to maintain quality of patient care. This report addresses aims 1, 2, 3 & 4 enabling each site to compare or benchmark their performance against national statistics. Audit Organisation The audit is a collaborative partnership between Gastroenterologists (the British Society of Gastroenterology), Colorectal Surgeons (the Association of Coloproctology of Great Britain and Ireland), Patients (the National Association for Colitis and Crohn’s Disease) and Physicians (the Royal College of Physicians of London). It is funded by a grant from the Health Foundation as part of their Engaging with Quality Initiative which aims to improve the quality of clinical care by engaging clinicians in quality improvement. The audit is a four-year, nation-wide, full cycle comparative audit with initial audit, dissemination, change implementation and re-audit. 5 UK IBD Audit 2006 Report The audit is co-ordinated by the Clinical Effectiveness and Evaluation unit (CEEu) of the Royal College of Physicians of London. Each hospital identified a lead from their IBD service and data were collected by hospitals using a standardised method. Data collection was overseen at site level by a lead agreed within the site IBD service. The audit was guided by a multidisciplinary IBD Audit Steering Group (Appendix 1) which oversaw the preparation, conduct, analysis and reporting of the audit. Who participated? 281 acute hospitals that admit patients with Inflammatory Bowel Disease (IBD) in England, Northern Ireland, Scotland and Wales (plus the Isle of Man and the Channel Islands) were invited to take part. 200 sites submitted data (England 159, Northern Ireland 10, Scotland 14, Wales 15, Islands 2). Of these 200 sites, 12 were Trust-wide sites combining 2 hospitals with a total of 212 hospitals entering data. We aimed to get 80% of applicable Acute Hospitals in the UK - a tough but realistic target for a discipline without any previous record of national audit- and achieved 75% participation. This response was