Article Text
PDF
Abstract
To objective of this project was to reduce unplanned hospital admission rates in children related to asthma to the Newcastle upon Tyne Hospitals National Health Service Trust (NUTH).
Multiple educational interventions were introduced both locally and regionally including: a collection of educational materials aimed at young people and families, schools, primary care and secondary care on the website www.beatasthma.co.uk; regional training days; a nurse-led one-stop clinic; a new pathway following an acute attendance to hospital with an asthma attack; a local asthma service and cascade training for schools.
The primary outcome measure was reduction in unplanned hospital admission rates in children due to asthma to the NUTH.
Results showed that admission rates had been increasing at a sustained rate of approximately 30% each year in the 3 years prior to our intervention. After the Beating Regional Asthma Through Health Education interventions, unplanned admissions to NUTH reduced by 29% and this reduction has been sustained for the last 3 years. This compares with a regional increase of 10% over the same time period.
In conclusion, simple but effective educational interventions resulted in a significant and sustained reduction in unplanned asthma admissions to NUTH. Further work is underway to extend the reach of these interventions into primary care and schools.
- adolescent health
- information technology
Data availability statement
Data are available upon reasonable request. The authors agree to make available the relevant anonymised patient-level data.
Statistics from Altmetric.com
What is already known on this topic?
The UK has the worse asthma outcomes in Europe and a lack of patient understanding as well as failure of health professionals to follow guidelines have been shown to be contributing factors.
What this study adds?
Simple interventions aimed at promoting health professionals’ adherence to national guidelines and supporting patient self-management through improved patient education can improve asthma control and reduce unplanned hospital admissions in a sustained way in a paediatric population.
Introduction
Asthma is the most common chronic condition in childhood1 and the incidence is increasing. The UK has amongst the worst asthma outcomes in Europe and young people in the UK are more likely to die from asthma than those in other high-income countries.2 Asthma can impact on all areas of a child’s well-being and children who are treated for asthma have been shown to have poorer educational and health outcomes than their peers.3
The National Review of Asthma Deaths 2014 (NRAD)4 highlighted systemic failings in the way we deliver asthma care in the UK with common avoidable factors contributing to deaths. It concluded that in all but one case, the care of children and young people (CYP) who had died from asthma in the UK had been inadequate and that their deaths were most likely preventable. It made 19 recommendations for how practice in the UK needed to change. But, with no funding to match, little has been done to implement these recommendations. Since the publication of NRAD, three coroner’s enquiries into the deaths of young people due to asthma, summarised in Regulation 28 statements,5–7 only serve to highlight our ongoing failure to meet these recommendations.
The National Health Service Long Term Plan8 sets out ambitious plans to prevent 80 000 hospital admissions a year from respiratory conditions and to tackle unacceptable outcomes in children’s asthma through a CYP’s Transformation Board and CYP clinical networks for long-term conditions focusing on asthma. If sustainable change is to be achieved, new thinking and approaches are needed at a systems level that allow care to be delivered seamlessly across geographical and institutional boundaries with a lack of barriers between services. Importantly, there needs to be a focus on education both of healthcare professionals and families and young people, allowing them to feel empowered and more able to self-manage their condition, a factor which is known to lead to improved outcomes.9
We report on one such approach: BReATHE (Beating Regional Asthma Through Health Education) is a new, innovative approach to improving asthma care and outcomes for CYP across the North East and North Cumbria, co-designed with patients, families, local authorities and health professionals and guided by the NRAD recommendations. This paper reports on the outcomes of these interventions across the city of Newcastle in the North East of England, UK.
The aim of the approach was to reduce unplanned hospital admission rates in children due to asthma to the Great North Children’s Hospital at the Royal Victoria Infirmary, a large tertiary centre in the North East of England, UK and 1 of only 14 major children’s medical centres in the UK, providing the full range of children’s health services.
Methods
Intervention design process
We used an experience-based co-design approach enabling users to be involved with all stages of development and provide feedback on key issues which were likely to impact on whether the final intervention can be successfully implemented. This included a regional paediatric partnership comprised of health professionals including representatives from primary to tertiary care, pharmacy as well as the local authority. Here, key problem areas were identified, and potential workable solutions were found that were broadly acceptable to all.
We ran co-design workshops for key service users involving (1) primary care professionals, (2) parents of children with asthma and (3) young people with asthma. These were run in collaboration with Open Lab at Newcastle University. Volunteers were recruited through adverts on General Practitioner websites and in hospital outpatients. The aim of the workshops was to elicit discussion and identification of areas of potential barriers and facilitators of quality care provision and suggestions for improvement.
Clinical intervention development
Using the results from the regional partnership discussions, the co-design workshops, the NRAD recommendations, national guidelines, Regulation 28 reports and the literature, a number of interventions were developed. The key areas of focus were (1) standardisation of paperwork and resources. The aim was for every healthcare professional in the North East and North Cumbria to use the proformas, flow sheets and resources to guide management, so as to ensure all were following the same management approach and offering the same high-quality care for CYP wherever they went to receive it. The aim was also to offer a consistent message for CYP and their families through the information sheets and leaflets, action plans and videos so they were getting the same message in the same way, wherever they received their care, thus promoting a sustained change in behaviour; and (2) education of healthcare professionals, families and CYP. It is well recognised that a multifaceted approach has the biggest impact (Szefler 2020), and with this in mind the following interventions were developed:
BeatAsthma
The foundation of the BReATHE interventions was BeatAsthma. This is a collection of over 150 resources hosted on www.beatasthma.co.uk (figure 1). The webpage has different portals of entry for different users as follows: families and children with asthma, young people with asthma, primary healthcare professionals, secondary healthcare professionals and schools. Each area has resources co-designed with and specific to the user and aims to offer a standardised approach to diagnosing and managing asthma meeting national recommendations, be that at home, in a healthcare setting or in a school, as well as educational materials to support management and understanding. It does this using management templates, information leaflets, educational videos and resources, and patient stories.
BeatAsthma online resource.
Regional training days
Supported by the BeatAsthma resources and using a face-to-face lecture format, five study mornings were held for primary care, focusing on the basics of children’s asthma including the NRAD report, managing children’s asthma, inhaler devices and technique, educating CYP and families, personalised asthma action plans (PAAPs) and spirometry.
One-stop clinic
A ‘one-stop nurse-led clinic’ was set up with the aim of targeting children being cared for in primary care. The clinic ran two times per month with four slots available in each. Children attending had either been referred from primary care or secondary care or had been invited to attend by a specialist asthma nurse doing the post-attack review phone call following an unscheduled hospital visit due to their asthma if deemed necessary. Those reviewed had pre-diagnosed asthma and it was felt would benefit from nurse time providing education, advice and support around managing their condition The visits were a once only 45-minute review, were supported by the BeatAsthma resources and covered the basics of asthma including a detailed Personalised Asthma Action Plan (PAAP), review of inhaler technique, an education session detailing what asthma is, what happens during an asthma attack and how the inhalers work, spirometry and a written report with recommendations to the referrer. If there were significant concerns regarding poor control following this appointment, patients were referred into a newly established asthma clinic for further follow-up. Every child/young person completed an Asthma Control Test (ACT) prior to their consultation which was repeated during a follow-up phone call 8–12 weeks later.
New pathway following an acute attendance to hospital with asthma
An asthma discharge bundle was developed comprising a collection of resources to help educate and empower families in asthma self-management. The bundle was given to families at the time of initial review and included a patient information leaflet, PAAP, inhaler technique information sheets, peak flow normal values, a checklist to outline what families should expect prior to discharge and a peak flow token to remind families to collect a peak flow metre prior to discharge. There were also prompt sheets for clinicians to ensure long-term control and potential risk factors were explored, as well as an acute management flow chart.
Weekly data were collected of the CYP presenting acutely to the Trust, coded as asthma. Families of these CYP were contacted by telephone during the following week to determine the progress of symptoms post-presentation. A proforma was developed to ensure that the families were asked the same questions about their child and their experience. As part of the phone call, they were asked if they had been given a PAAP, had their inhaler technique checked and had been given immediate post-discharge advice including a GP follow-up within the 48-hour national recommendation. Some of these families were invited along to the one-stop nurse-led clinic, particularly if they had had repeated admissions or if the nurse making the call felt they would benefit from it. Unfortunately, resources did not allow for all families to be offered this.
Local asthma service
A local asthma service was created, run by a paediatrician with special training in paediatric asthma and supported by a respiratory nurse specialist. The clinic ran monthly and took referrals from primary and secondary care, as well as those patients highlighted at the one-stop clinic, the post-discharge phone calls or following an acute admission as being at higher risk. Supported by the BeatAsthma resources, patients had a review of overall asthma control, lung function, fractional exhaled nitric oxide level, education, inhlaer technique review, discussion on adhrence and if required, allergy tests as well as treatment changes as needed.
Cascade training for schools
Alongside the Newcastle Council School improvement service, training sessions were developed and delivered to local schools around managing asthma. These incorporated the use of generic emergency salbutamol inhalers at school.10 A BeatAsthma emergency inhaler guidance pack for schools was developed which included an asthma attack procedure flow sheet, inhaler device information and various templates for record keeping to be used in schools.
Two times per year, managing medical conditions in schools’ training sessions in line with the Department for Education statutory guidance were delivered to school staff with a session on asthma being part of this.11
Work raising asthma awareness among school health nurses was undertaken. A PowerPoint presentation was prepared for this group of professionals to deliver to their allocated schools. The session was delivered as part of school health nurse training days across five local regions for them to cascade out.
Patient and public involvement
Patients were involved in all stages of the design and conduct of this study and continue to be involved in the further development of BeatAsthma. The work was initially prompted following conversations with families of children with asthma about the lack of resources available to them to help them understand and manage their child’s asthma during acute and routine care visits. Choice of interventions, design of the BeatAsthma online resource and the specific resources included as well as the outcome measures for the study were informed by discussions during patient and family focus groups. A number of the participants from these focus groups then became editors on the BeatAsthma editors’ group and wrote and reviewed resources. One has been involved in the promotion in the local media. Once the trial has been published, the results will be made available through the ‘patients and families’ portal of the BeatAsthma website in a format that is suitable for a non-specialist audience.
Finance
The intervention was implemented with minimal upfront funding. Time was given freely by all BeatAsthma editors both for the development and delivery of the website, and interventions were either temporarily incorporated into existing job plans or done in the free time of the professionals involved. The project received a one-off charitable donation from the Children’s Foundation Charity for the build of the website and 1 day per week nursing time for a band 7 nurse was provided by Newcastle upon Tyne Hospitals NHS Trust (NUTH) for 1 year.
Outcomes
The primary outcome measure was a reduction in unplanned hospital admission rates in children due to asthma to the NUTH. An unplanned admission is defined as any completed spell where the admission method was an emergency or a transfer from another hospital provider and the International Classification of Diseases, 10th revision primary diagnosis code of the admitting episode of the spell was in the range J45–J46 (asthma and status asthmaticus) or R06.2 (wheezing). Children were eligible if they were between the ages of 5 and 16 years inclusive.
Secondary outcomes were (1) an improvement in the number of eligible children with asthma who had received a PAAP in the previous 12 months in both primary and secondary care, and (2) an improvement in asthma control overall. This would be measured using the validated ACT score with a 2-point change being recognised as a clinically significant difference.12
Results
Admission rates had been increasing in a sustained way of approximately 30% year on year in the 3 years prior to our intervention. After the BReATHE interventions, unplanned admissions to NUTH reduced by 29% (128 to 91 admissions) and this reduction has been sustained for the last 3 years. This is on a region-wide increase of 10% over the same time period (figure 2). On admission costs alone, this equates to a cost saving of over £67 000.00 and this figure does not take into account the cost of lost working days for parents, lost school days for CYP and impact on quality of life.
Changes in asthma-related unplanned admission rates over time. BReATHE, Beating Regional Asthma Through Health Education.
Each of the 13 secondary care provider trusts and a number of primary care providers in the North East and North Cumbria adopted the standardised BeatAsthma paperwork and resources.
The number of eligible children receiving a PAAP increased from 5% to 53% in primary care (Newcastle Gateshead Clinical Commissioning Group) and from 30% to 80% in secondary care (NUTH) (figure 3).
Percentage of eligible patients in receipt of a personalised asthma action plan (PAAP).
One hundred and twelve professionals attended the morning training, with representation from 64 GP practices in the North East. Delegates were mainly practice nurses but included 13 GPs and 6 school health nurses. Feedback was positive with all sessions rated as good or excellent on evaluation.
Sixty-six children (age range 5–16 years, M:F 1.9:1) were reviewed in the nurse-led one-stop clinic over a period of 12 months. Sixty children completed ACTs and 43 completed a repeat ACT during a follow-up phone call. From being seen in the one-stop clinic to 3 months later, the mean ACT score changed from 15.4 points (SD 5.85) to 21.9 points (SD 5.06). The proportion of children whose score suggested inadequate control changed from 70% (42 children) to 30% (13 children). A score of 19 or below suggests inadequately controlled asthma. Feedback from patients was overwhelmingly positive.
One hundred and eighty children were recorded as being emergency presentations to Emergency Department. Attempts by a specialist nurse to contact the family by telephone following the acute presentation were made in 71% of cases. In 59% of these cases, the nurse was able to speak with the family and perform a follow-up review. The remaining calls were unsuccessful due to either the family not answering or returning the call or incorrect telephone details. Nine per cent (17 patients) were reviewed during their inpatient admissions, a further 4% were already known to specialist services and reviewed accordingly.
The BeatAsthma online resource has had over 35 000-page views worldwide to date and 100% positive feedback from all user groups. There has been increasing use nationally and approaches for translation for international use.
Three school training sessions were delivered around emergency inhaler use in schools with 55 schools attending and all delegates rating the session as excellent.
The ‘managing medical conditions in schools’ sessions were set up prior to this work and were attended by 370 delegates—again feedback for the asthma session rated excellent by the majority of delegates.
A summary of the results can be seen in figure 4.
Results infographic. ACT, Asthma Control Test; PAAP, personalised asthma action plan.
Discussion
Principal findings
With simple educational interventions, we have been able to reduce unscheduled admissions for children’s asthma by almost one-third. In addition, these reductions have been sustained while elsewhere admissions have continued to increase. Overall, asthma control has also improved, and the interventions have been well received by patients, families and professionals alike.
Strengths and limitations
The interventions used were relatively simple and have been easily transferred to other healthcare settings. As the study had multiple levels of intervention, it is impossible to pinpoint which individual intervention was responsible for this change. However, the aim for all interventions was the same, to improve asthma control in children in the North East and Cumbria by improving education of healthcare professionals and patients alike. Using unscheduled admissions as the main outcome measure is a fairly gross tool and other subtler measures are likely to have also improved, as demonstrated by the increase in ACT score following attendance at the one-stop clinic. Unfortunately, we were only able to hold the one-stop clinic in one centre due to lack of funding, this may explain the 10% increase in admissions seen elsewhere in the region. The study would have been stronger if we had been able to have multiple one-stop clinics (ideally in a primary care setting) throughout the region.
Comparison with the literature
Previous studies have shown that asthma education for children and families can reduce hospital admissions.13 Despite this, there continues to be excessive hospital admissions with childhood asthma in the UK.2 There are limited data of this kind of multiple intervention study to improve asthma care in childhood. Further work is underway to increase the spread of these interventions across the region, in particular into primary care including the development of a comprehensive, online paediatric asthma education module for healthcare professionals which will be available next year.
Conclusions
In conclusion, a series of simple but effective educational interventions resulted in a significant and sustained reduction in unscheduled asthma admissions in the NUTH. The resources are freely available, and these interventions can be easily replicated in other centres. The provision of a named paediatrician and asthma nurse with appropriate training was essential to the success of these interventions, both in the delivery of care and lead on whole system change within the local area and would be essential to any area wanting to replicate this work.
Data availability statement
Data are available upon reasonable request. The authors agree to make available the relevant anonymised patient-level data.
Ethics statements
Patient consent for publication
Acknowledgments
Thanks to the BeatAsthma editors from across the North East and Cumbria, including health professionals, the families of children with asthma and the children and young people themselves, all of whom contributed to the design of the interventions and development of the resources and continue to do so. Special thanks to public/patient contributor Samantha Berry for her ongoing dedication to BeatAsthma. Thanks to Professor Julia Newton for her help with preparation of the final manuscript.
Footnotes
Contributors JKT led the design, delivery, analysis and write-up of the project. SH, RL, PD, MM and SM contributed to the design, delivery, analysis and write-up of the project.
Funding The study received a one-off charitable donation from the Children’s Foundation Charity for the build of the website. One day per week nursing time was provided by Newcastle upon Tyne Hospitals NHS Trust for 1 year.
Competing interests JKT is a subject matter advisor of the HSIB investigation into childhood asthma and an unpaid member of CYP Transformation Team Asthma oversight group, no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years. SM has received funding to speak at educational events from Novartis Pharmaceuticals UK, unrelated to this article, no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.