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) 1 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. 2 Asthma A&E attendances in Harrow as significantly worse than the average for England 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) – BTS/SIGN

Audit criteria to be measured 1. Existing asthma treatment before the attack: – Reliever – Preventer – Spacer? 2. Prescribing in 12 months before the attack: – 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? 4. Personal asthma action plan 5. Assessment and treatment during 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? 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