Systems of care | Effectiveness and Education

Asthma A&E/Short stay Pathway

Evelina London Children's Hospital
Dr Emma Dyer
The initial problem and its impact

Patients with asthma frequently come through A&E with exacerbations of symptoms. We are generally good at managing the acute presentation of asthma. However, we were not as good at thinking about long term management and risk factors such as recording smoking status of parents, organising the correct follow up, asking about medication compliance and assessing inhalor technique. In Europe we have the one of the highest mortality rates in paediatric asthma, and the national review of asthma deaths identified that one of the main problems is patients not getting basic asthma healthcare including annual review, checking inhalor technique and having a written asthma plan.

Causes of the problem

In A&E there is very much a focus on the acute presentation and management. However, many patients with asthma don't make it into the ward and are just managed in A&E or the short stay unit. Therefore we need to ensure we are thinking about the long term management, prevention of exacerbations, patient education and follow up as well as the acute management. 

Project aim statement

To ensure every patient seen with Asthma in A&E or the short stay unit is having the severity of their long term condition assessed, inhalor technique checked, risk factors and triggers documented, a written asthma plan given and appropriate follow up arranged. 

Stakeholders
  • Paediatric A&E medical staff
  • Paediatric A&E nursing staff
  • General paediatrc and paediatric respiratory teams
  • Patients with asthma and their families.
PDSA Cycles / solution(s) tested

Initially we introduced a proforma for all patients attending with wheeze and asthma. This included prompts for severity assessment, risk factors (including smoking status) and a discharge checklist. This greatly improved the smoking status recording and the objective assessment of severity of disease. However, we recording of assessment of inhalor technique, providing a written asthma plan and arranging appropriate follow up remained very poor. 

Data results
  • Recording of smoking status has gone up from 23% to 51%.
  • Objective assessment of severity has increased from 67% to 99%.
  • Only 50% had it documented that they had been given a written asthma plan
  • Only 13% had it documented that their inhalor technique had been assessed. 
  • 21% had no follow up arranged
  • Only 45% had it documented that they were advised to see a GP within 48h of discharge
How this improvement will be sustained

We have now redesigned the proforma - it has been split into two proformas which are shorter. One for A&E, and a second one for if they are admitted to short stay. This now includes a clear outline of what follow up patients require depending on their history and presentation. There is also a shorter discharge checklist which includes sign offs to say that inhalor technique has been assessed, they have been advised to see a GP within 48h, they have a written asthma plan, smoking cessation advice given if required and appropriate follow up has been arranged. We are now carrying out education sessions with the new proformas and highlighting the discharge checklists as the new part of the proforma to ensure is completed. 

Challenges and Learnings

Changing the mindset to move away from only treating the acute exacerbation and thinking in more detail about the long term management and follow up to try and prevent further exacerbations. We have been getting the junior doctors and nursing staff involved to get their feedback on the current proforma and have incorporated their ideas into the new proformas. 

Suggestions for further implementation

We are going to re-audit this following the introduction of the new proforma and see whether this improves the recording of the severity of their long term condition, inhalor technique checked, risk factors and triggers documented, a written asthma plan given and appropriate follow up arranged. Depending on the findings we may further refine the proforma to aim to improve this further. 

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