Implementation of a Children's Safe Asthma Discharge Care Pathway Reduces the Risk of Future Asthma Attacks in Children–A Retrospective Quality Improvement Report

Abstract

BackgroundMany children attend Emergency Departments (ED) and Out of Hours (OoH) frequently for acute asthma. Follow up care is often suboptimal leaving these children at risk of a future attacks. We report on the development, implementation and evaluation of a safe asthma discharge care pathway (SADCP).MethodsThis is a retrospective report on the development, implementation and evaluation of outcomes of a SADCP. The pathway was based on the Teach-to-goal educational methodology that supported the mastery correct inhaler technique and ability to action the personalized asthma action plan (PAAP). Children with frequent asthma attacks were entered as they were discharged from the Emergency Department or ward. The first training session occurred within 1–3 weeks of the index asthma attack with 2 further sessions in the following 8 weeks. Children exiting the pathway were discharged either back to primary care or to a hospital clinic.Results81 children entered the pathway (median age 5 years) with 72 discharged from the ED and 9 from the medical wards of the Royal Belfast Hospital for Sick Children. At pathway entry 13% had correct inhaler technique, 10% had a Personalized Asthma Action Plan (PAAP), and 5% had >80% (45% >50%) repeat refill evidence of adherence to inhaled corticosteroid over the previous 12 months. On pathway exit all children demonstrated correct inhaler technique and were able to action their PAAP. One year later 51% and 95% had refill evidence of >80% and >50% adherence. Comparisons of the 12 months before and 12 months after exit from the pathway the median number of emergency ED or OoH asthma attendances and courses of oral corticosteroids reduced to zero with >75% having no attacks requiring this level of attention. Similar findings resulted when the SADCP was implemented in a district general hospital pediatric unit.ConclusionImplementing an asthma care pathway, using Teach-to-Goal skill training methods and frequent early reviews after an index asthma attack can reduce the future risk of asthma attacks in the next 6 to 12 months.

Medication Adherence in Children with Asthma

“…While not advocating reduced compliance with the prescribed treatment regime, a study of children's asthma has shown clinical improvements when patients increase the frequency with which they use their inhaled corticosteroid, even if still below that prescribed. 30 …”

“… 30 , 39 In order for the benefits of the PAAP to be fulfilled, a teach-back approach must be used to ensure complete and sustained understanding by the patient/carer. 30 …”

“…Similarly, a retrospective study of children's asthma in the UK showed that the implementation of a structured asthma care pathway on discharge following an attack, with a focus on patient education and self-management, reduced the rate of attacks over the next 12 months. 30 Is Full Adherence Necessary?…”

“…While not advocating reduced compliance with the prescribed treatment regime, a study of children's asthma has shown clinical improvements when patients increase the frequency with which they use their inhaled corticosteroid, even if still below that prescribed. 30 Steps need to be taken to ensure that future research adopts the most appropriate outcome measures and consistent methods of measuring adherence (to include not just rate of inhaler use but also quality of inhaler technique) to accurately address this important question. 17…”

Hospital discharge using salbutamol as required after acute attacks of wheeze in children: a service evaluation

“…While paediatric care plans for acute wheeze advise treating worsening symptoms with salbutamol every 4 hours as needed, discharge care plans typically advise reducing doses of bronchodilator according to predetermined, fixed dose regimes 1 2. There is no clear discharge advice for salbutamol use in national guidelines, but advice that patients can be discharged when stable on regular 3–4 hourly bronchodilators has resulted in many hospitals recommending continued use of regular bronchodilators after leaving hospital 3.…”