Clinical

Acute management

Inflammatory Bowel Disease

Background

This table should be read in conjunction with the table on IBD that in the chronic disease section. This table deals with IBD in relation to hospital inpatient care.

  • The two most common forms of Inflammatory Bowel Disease are Crohn’s Disease and Ulcerative Colitis (UC). Together they affect 1 in every 250 people in the UK giving an estimated population of 240,000. Half of those diagnosed will be in their teens or twenties. These are lifelong conditions as there is no cure.
  • Ulcerative colitis: Less than 20% of patients will experience their first attack of UC as an acute severe episode. For diagnosed patients, about 17% will at some point experience a severe episode with acute symptoms of diarrhoea, pain and fever requiring immediate admission and treatment. 30% of those admitted will need a colectomy.
  • Crohn's Disease: patients may present with acute severe inflammation or blockage of the small intestine due to a stricture.
  • Mortality risk with acute severe admissions should be very low but has been shown in previous audits to be highly variable.

Patient View

  • Patients who already have a diagnosis of IBD and who are admitted as an emergency sometimes find there are significant delays before they are transferred into the care of the specialist team. This makes for a very poor experience and delay can contribute significantly to poorer outcomes.
  • Patients wish to be cared for in a specialist GI ward area with adequate toilets (IBD Standards: no more than 3 beds per toilet).
  • Patients wish their care to be coordinated with access to the key professionals to discuss important treatment decisions without system-imposed delays. This may be a decision about surgery for IBD after having a discussion with the surgeon and gastroenterologist together.
  • Patients wish to have an agreed care plan in place when discharged so that they and their GP know what is intended for their future management.

Current Practice

  • Patients with acute severe ulcerative colitis are usually treated with intravenous steroids, then ciclosporin if not responding to corticosteroids, or infliximab if ciclosporin is inappropriate. A decision on surgery should normally be made after 72 hours.

Recommended Practice and Opportunities for Integrated Working

  • NICE Guidelines for Crohn’s and UC are being developed.
  • Clinical Guidelines have been produced by the British Society of Gastroenterology and the European Crohn’s and Colitis Organisation. A key recommendation is management by a multidisciplinary team combining a gastroenterologist and colorectal surgeon specialising in IBD.
  • IBD Standards: National standards for the care of IBD patients have been developed by a collaboration of health professional and patient organizations and these are used as the basis for national audit. (www.ibdstandards.org.uk).
  • The IBD Standards state that hospitals should have defined arrangements for admission of IBD patients into the specialist gastroenterology ward area where possible, and for transfer of IBD patients to specialist IBD care within 24 hours of admission.
  • Hospitals should have written guidelines for the management of acute severe ulcerative colitis.
  • NICE recommends the use of infliximab for acute severe UC where the use of ciclosporin is inappropriate.

Opportunities for Savings

  • There is little scope for savings, but there are opportunities for service improvement and better use of resources leading to higher quality care for patients.

Quality Indicators (Outcomes)

Clinical management

  • Crohn’s & Colitis Deaths: Too infrequent for statistical analysis but the proposed quality standard is confirmation that each death has been subject to a CEPOD-type review.

Patient reported experience and outcomes

  • Quantitative and qualitative patient evaluations are undertaken and acted on annually
  • IBD PROM if and when validated.

Process metrics likely to impact on outcomes (Adherence to IBD Standards) eg:

  • Participation in national audits including the HQIP supported UK IBD Audit (100%)

Acute care: outcomes

  • Rates of Intestinal perforation with confidential enquiry on each episode of death and of non-fatal perforation.
  • Patient quality of life and/or PROM following acute admission.

Acute care: process measures

  • Patients are under a specialist MDT within 24 hrs of acute admission (90%/95%/100%)
  • Percent use of venous thromboembolism prophylaxis
  • Time to colectomy
  • Utilisation of salvage therapy

References