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Research to understand childhood asthma in London

This research involves a simultaneous baseline audit and a prospective audit of patients soon after they are treated for an attack in the general practice, A&E, an urgent treatment centre or in a hospital. It aims to determine whether there are factors that could have helped prevent a patient’s attack.

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Background

The National Review of Asthma Deaths (NRAD) identified a number of preventable factors related to the management of people who died from asthma. Some of these related to management during the final attack.

Asthma attacks are an indication of a failure to control the disease, either by health professionals or patients (& their carers) themselves.

This audit is intended to highlight potential preventable problems related to the management of attacks and also to stimulate change by health professionals in the treatment of attacks; in particular by assessing all patients within a few days of treatment for an attack and optimising treatment and reducing future risk.

An audit with a difference

This audit is being conducted by Dr Mark L Levy, Respiratory Lead for Harrow. There are two stages in one:

  • a simultaneous baseline audit (for a time period ideally, six months, last year)
  • a prospective audit (ideally for a year but you decide on the time period – at least 6 months) of patients soon (within a few weeks) after they are treated for an attack, irrespective of whether this is in the general practice, accident & emergency, an urgent treatment centre or in a hospital.

In doing this audit, doctors and nurses will quickly be able to determine whether there were preventable factors that could have helped prevent each patient’s attack.

Identification of patients

All children and young people (CYP) aged 0-19 (ie <20 years), during  the six months last year, eg from 1.3.2015 – 30.9.2015) and then prospectively ideally for a year:

  • Been admitted to hospital for asthma/wheezy attacks, or
  • Been treated for asthma or wheezy attacks in: A&E, or  ED, Urgent Treatment Centre (UTC), or GP practice

For the baseline audit, search your records to identify children and young people  < 20 years old admitted to hospital or treated for attacks during a six month period last year (the baseline audit); and at the same time identify patients from now on, prospectively, (the prospective audit) who are admitted to hospital or treated for attacks in practice or A&E or UTC/Walk-in Centre.

Clinical Audit Standards (based on Global Initiative on Asthma, London asthma standards for children and young people and Recommendations from the National Review of Asthma Deaths(NRAD)

 General standards

  • All children and young people prescribed more than 6 short acting bronchodilator reliever inhalers (SABAs) in the previous year should also be prescribed inhaled corticosteroids (or another preventer drug)
  • All children and young peoplewith 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 children and young people over five years should have a record of their best Peak Expiratory Flow
  • All children and young people 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 Expiratory 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:

  • This review should include checking inhaler technique, whether a Personal Asthma Action Plan has been issued or needs modifying, and what triggered the attack
  • The review should also include optimisation of treatment (we are not measuring this directly in this audit, rather deriving this from your responses to the final ‘reflection’ section of the audit sheet.

Oral Corticosteroids should be continued until the attack has resolved (as determined by the or health professional)

Adverse outcome

Re-attack within four weeks of treatment – this should be a ‘never event’ – if any of your patients satisfy this criterion, it may be advisable to make a referral to a specialist for advice. Sources of information on treatment of asthma: International GINA Asthma strategy document and NICE Quality Standard 25Gina Pocket Guide from Amazon.

Doing the audit

For UK practices, use your Practice Code, for others use a self generated personal identification code by starting with your country dialling code and adding your name – eg 44DRMARKLEVY. Also allocate a unique confidential identification number for each patient audited, and keep a log of these, in case you need to contact the patient for asthma review and optimisation of care.

The baseline and prospective audits are done simultaneously. Download and use the data-collection pro forma form. This is a word form that can be completed on your computer and printed for your records. Alternatively, print copies and complete them manually.

Complete one form for each patient you identify, mark the sheets with either baseline (for patients treated last year) or prospective (for the patients treated for the next 6 months).

Use the online audit completion tool to copy your audit results in the online form

Most average sized practices will have about 10 to 20 children and young people with attacks in the baseline and prospective audit; however, please enter all those that satisfy the entry criteria. Collecting the data and entering it online should take 10-15 minutes for each patient.

Important points to remember

  • Enter your personal/practice ID on each patient form you complete, and
  • Ensure you use the same confidential identifier for those patients who have more than one attack so that we can report on the the incidence of re-attendances
  • Click ‘submit’ at the end of each form you enter

After completing the audit, if you would like a personalised report of your results (based on the above standards) compared with those of others, please send your Practice Code/personal Identification code and a contact email address to Dr Mark Levy at mlevy1@nhs.net

Further reading

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