PICH Childhood Asthma project
Bina Chauhan
Locum GP
4/5/16
Why asthma?
• Asthma deaths are preventable.
• 1.1 million children in the UK are currently
receiving treatment for asthma (1 in 11)
• A child is admitted to hospital every 20 minutes
because of an asthma attack.
• Attacks are often treated as isolated events
without follow-up or optimisation of chronic
treatment.
• Asthma A&E attendances in Harrow as
significantly worse than the average for England.
1
2
3
1. asthma.org.uk 2. GINA 3. Chimat profiles
National review of asthma deaths
• NRAD 2012 identified a number of preventable factors:
– Excessive relievers/insufficient preventers
– Failure to provide personal asthma plans
– Attacks may have resulted from inadequate tx or education
recognising danger signs
• Asthma attacks indicate a failure to control disease, by
health professional or patients.
What I would like to achieve
• Better asthma education for children, families
and local GPs.
• Personalised and realistic action plans to
improve overall control.
• Better recognition and treatment of acute
exacerbations.
• Improved shared care between primary and
secondary care.
Aim of baseline audit
• To investigate the assessment and management of
asthma exacerbations in children and young people
age 0-19 years over a 6 month period between 1/4/15
– 1/10/15.
• To assess routine asthma management prior to an
exacerbation.
• To help practices quickly determine whether there
were preventable factors that could have helped
patients avoid attacks and therefore helped to avoid an
admission. Presented at practice meeting.
Standards
• London asthma standards
• Global Initiative for Asthma (GINA)
– www.ginasthma.org
• BTS/SIGN
Audit criteria to be measured
•
1. Existing asthma treatment before
the attack:
•
4. Personal asthma action plan
•
5. Assessment and treatment during
the attack:
– Reliever
– Preventer
– Spacer?
•
2. Prescribing in 12 months before
the attack:
– Peak flow measured?
– Sa02 measured? If yes, before and after
treatment?
– Salbutamol given? If yes, neb or spacer?
Oxygen or air?
– Prednisolone prescribed? If yes, dose
and duration?
– Number of relievers prescribed
– Number of preventers prescribed
•
3. Last routine asthma review:
–
–
–
–
Date
Control assessed? If yes, poor or good?
Risk factors identified? If yes, which?
Inhaler technique checked? If yes, poor
or good?
– Record of previous best peak flow? If
yes, what was it?
•
6. Date reviewed after attack
Methodology
• Emis search for CYP age 0-19 years at Simpson
House Medical Centre, Harrow
• ReadCode searches for: Asthma, wheeze,
asthma exacerbation
• Time frame: 1/4/15 – 1/10/15 (6 months
retrospective)
Results, Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• 3/12 (25%) patients were prescribed 6 or more
SABAs in the 12 months before, they were all
prescribed ICS, however all three were poorly
controlled when they had their last asthma
assessment, indicating their treatment needed
optimising.
Two of the three had their inhaler technique
checked, and one of these was poor, probably
explaining why the patient was poorly controlled
and had a subsequent attack
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• None of the 12 patients had evidence in their
record of being provided with a personal
asthma action plan
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• Only 3 of the 9 (over 5yrs) had a record of
their best PEF
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• Only 3 of the 12 (25%) prescribed inhalers had
evidence in their record of having had an
inhaler technique check
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• Only 6/12 (50%) had their saturations
checked.
1 was re checked after treatment.
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• Only 3 of the 9 (30%) had PEF measured
before treatment and none after.
Summary & Discussion
General standards:
• All CYP prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous
year should also be prescribed inhaled corticosteroids (or have a record detailing why this is not
justified)
• All CYP with asthma should have evidence of being provided a Personal Asthma Action Plan
(detailing medication administration, trigger factors and their avoidance, identification of danger
signs of attacks, and what to do when these occur)
• All CYP over 5 years should have a record of their best Peak Expiratory Flow
• All CYP prescribed inhalers must have evidence in their records of having their inhaler technique
assessed
During attacks:
• All CYP should have a measurement of oxygen saturation, repeated after treatment if abnormal.
• All CYP over age 5 years should have a measurement of Peak Flow (to include one after first dose of
oral steroid treatment to assess whether treatment was successful)
After treatment of the attack:
• All CYP prescribed oral corticosteroids should be reviewed within 2 working days of starting
treatment with oral corticosteroids.
• Not one of the CYP had an assessment within a few
days after the attack – this included the child who by
BTS/SIGN definition had a life threatening attack (SaO2
92% before and after initial treatment)
This review should include checking inhaler technique,
whether a Personal Asthma Action Plan has been issued
or needs modifying, and what triggered the attack.
Oral Corticosteroids should be continued until the attack
has resolved (as determined by the health professional)
• Patient experience and involvement
– Asthma plans with longer appointments
– Mini focus groups
• Data influencing change
– Audit results to aid improvement for 1 practice
• Working clinically in an integrated way
– Respiratory lead for Harrow CCG
– Asthma nurse
• Leading the development of integrated services
– Working towards increased nurse involvement to help
follow up post A&E attendance.
– Better communication A&E and GP with shared care
The next step
• Face to face asthma plans for the 12 identified
children with the asthma nurse present.
• Re audit in June (3 months retrospective)
following GP education/presentation.
• Continued working towards more integrated
services:
– ? A dedicated post exacerbation clinic
– ? Targeting repeat A&E attenders