adult asthma secondary care audit good practice repository

Adult asthma secondary care audit

Good Practice Repository – Elements of good practice

Version 1.0: January 2021

Introduction The National Asthma and COPD Audit Programme (NACAP) have collated a series of case studies which highlight good practice in the provision of six elements of good practice care for patients with asthma. This document aims to provide teams with insight into models of care delivery from hospitals achieving high levels of concordance with guideline defined standards of care. Do you have any questions? If you would like more detail about any of the case studies provided here, please contact the NACAP team on 020 3075 1526 or via email ([email protected]). For further information on NACAP, please visit www.rcplondon.ac.uk/nacap

Contents

George Eliot Hospital (George Eliot Hospital NHS Trust)........................................................................ 2

St Mary’s Hospital (Imperial College Healthcare NHS Trust) .................................................................. 3

Lister Hospital (East and North Hertfordshire Hospitals) ....................................................................... 4

Maidstone General Hospital (Maidstone and Tunbridge Wells NHS Trust) ........................................... 5

Manchester Royal Infirmary (Manchester University NHS Foundation Trust) ...................................... 6

Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare NHS Foundation Trust) .. 7

Poole Hospital (Poole Hospital NHS Foundation Trust).......................................................................... 8

Appendix A: George Eliot Hospital out–patient proforma ..................................................................... 9

Appendix B: George Eliot Hospital discharge advice sample ............................................................... 10

Appendix C: St Mary’s Hospital asthma discharge bundle ................................................................... 11

Appendix D: Lister Hospital asthma discharge care bundle ................................................................. 12

Appendix E: Lister Hospital asthma discharge bundle ......................................................................... 13

Appendix F: Manchester Royal Infirmary adult asthma inpatient assessment sheet ......................... 14

Appendix G: Poole Hospital in-patient asthma review new patient .................................................... 15

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Good practice repository – Elements of good practice National Asthma and COPD Audit Programme (NACAP) [email protected] I 020 3075 1526 I www.rcplondon.ac.uk/nacap of 15

George Eliot Hospital (George Eliot Hospital NHS Trust)

• The respiratory team at George Eliot Hospital aim to ensure that all patients admitted to

hospital with an asthma exacerbation are provided with six elements of good practice care.

• The BTS discharge care bundle is used for all patients seen by the respiratory team to

ensure patients receive all the elements of good practice care.

• The respiratory team ensure that all patients receive a personalised asthma action plan

and a specialist follow-up appointment within two-weeks of discharge.

Effective teamwork and coordinated approach:

• The respiratory team have a proactive and coordinated approach shared between

respiratory consultants, asthma nurses and the clinical audit team. The ‘team approach’

helps to ensure that all patients receive the necessary care, and that this care is

accurately and promptly recorded on the NACAP web tool.

• The asthma team also:

o provide education across the Trust, to ensure all hospital staff know how to access

specialist asthma support for relevant patients.

o provides specialist nurse-led reviews with consultant support, Monday to Friday.

o are able to see patient both in and outside of set clinical times as they have the

availability of a dedicated respiratory ward.

o have developed and utilised a specialist review proforma for outpatient follow-

up reviews to ensure all elements of best practice care are provided. (please see

appendix a and appendix b)

The respiratory team at George Eliot Hospital noted that the feedback they receive from asthma

patients is ‘positive and encouraging’, for ‘a population with difficult to treat asthma’.

Examples of patient feedback:

“I have regular appointments at the asthma clinic, and I have always received the best advice and

help when necessary for my condition. Top Grade!”

“Extremely likely to recommend respiratory team and asthma ladies.”




St Mary’s Hospital (Imperial College Healthcare NHS Trust)

• The respiratory team at St Mary’s Hospital are able to provide the six elements of good

practice care for their asthma patients by utilising available systems and ensuring effective

team working.

Utilising available systems

• The respiratory team makes use of all available systems including community databases.

This provides the team with important information on a patient’s: concordance with their

medications, their immunisation and assessment history and any previous reviews

provided by different services and departments.

• The team routinely liaises with the treating medical team to ensure that all elements of

best practice care are achieved and addressed. This is also useful in ensuring that all

aspects of care are achieved, but not duplicated. There is a daily triaging of respiratory

patients admitted at the hospital.

• An audit proforma is attached to each asthma review, allowing for greater accuracy in

data collection. Audit data is then entered into the NACAP web tool in a timely fashion.

• Prior to discharge, the respiratory team ensure that all patients with asthma are given an

individualised asthma action plan where the team’s contact details can be found.

• An internal asthma bundle is completed on all asthma admissions ensuring elements of

good practice are reviewed and addressed (appendix c).

• The team is adapting inpatient coding to ensure greater accuracy in reporting.




Lister Hospital (East and North Hertfordshire Hospitals)

• The respiratory team at Lister Hospital are able to provide the six elements of good practice

care for asthma patients at their hospital thanks to their 7-day service, and a good team

effort.

• The majority of asthma patients admitted to Lister Hospital receive a timely review and

have their asthma care optimised.

• A coordinated and good team effort has allowed patients to receive their correct diagnosis

and access to their correct treatment pathway.

• The respiratory team are able to empower patients by providing them with education to

encourage self-management of their asthma. Where necessary, the team escalate a

patient’s care to the respiratory consultant and ITU.

• In order to ensure that the team provide all the elements of good asthma management, an

audit A4 proforma (appendix d) and sticker (appendix e) is attached to their patient notes.

• Dedicated time is also allocated, where possible, to allow for data to be inputted into the

NACAP web tool.




Maidstone General Hospital (Maidstone and Tunbridge Wells NHS Trust)

• The respiratory team at Maidstone General Hospital aim to review all patients admitted to

their hospital with asthma. They achieve this by requesting early referrals, but also by

searching ward inpatient lists and A&E attendee’s lists.

• The team are provided with a list of discharged patients who were admitted due to their

asthma exacerbation, and these patient records are included in the adult asthma audit.

They have noted a decline in the number of patients missed since employing these

methods.

• An asthma review sheet and discharge bundle sticker, which includes the six elements of

good practice care, are also used by the team. They noted that prior to using these

documents, elements of good practice were discussed but not always recorded.

• The team are committed to further developing their asthma service by ensuring the

provision of follow-up appointments, and improving their ability to foster communication

between patients and multidisciplinary teams.

• The respiratory team note that they are currently writing a business case for asthma nurse

specialists and are keen to explore setting up ‘satellite clinics’ for biologics commenced at

tertiary centres. The team are keen to hear from any other hospital teams that may have

examples in these areas.




Manchester Royal Infirmary (Manchester University NHS Foundation Trust)

• The respiratory team at Manchester Royal Infirmary aim to ensure that each patient

admitted to hospital with an asthma exacerbation is reviewed by a specialist asthma nurse

before discharge.

• If this is not offered, then an appointment is arranged for 2-4 weeks following a patient’s

discharge.

• The team noted that their success in achieving this is down to long-standing and improving

team working.

Long-standing team practices:

• In 2012, an asthma discharge bundle was devised, and a standardised asthma plan was

used across secondary and primary care.

• In 2014, the discharged bundle was revised to include best practice and PEFR charts were

updated to include predicted PEFR values on the reverse. (appendix f)

• In 2016, a respiratory teaching study day was introduced on a quarterly basis for ward staff;

aimed at discussing the importance of referrals to specialist services, PEFR and inhaler

techniques.

• The team also then formed a specialist obstetric asthma clinic and began taking part in the

NACAP audits.

• In 2019, collaborative work was taken with the Emergency Department to revise the

asthma pathway for patients to reflect those patients who need secondary care input due

to readmission.

Resource support:

• In 2008, x1 band 7 staff member was employed to set up a ‘service designated nurse

specialist clinic for asthma’ which included daily visits to all acute areas to highlight the new

service.

• In 2016 x1 band 6 staff member joined the service with increased clinic capacity to facilitate

increased service cover.

• In 2018 x1 airways consultant was appointed to enable specialist obstetric clinic and in-

house referral for severe asthma.

• In 2019, x1 band 5 staff member was appointed to help input NACAP data by tracking

asthma and COPD admissions.




Northumbria Specialist Emergency Care Hospital (Northumbria Healthcare

NHS Foundation Trust)

• Northumbria Specialist Emergency Care Hospital (NSECH) noted that they consistently

perform well above national average in delivering asthma care bundles to patients

admitted with an asthma exacerbation. They aim to deliver a care bundle to all patients.

• NSECH is England’s first purpose-built specialist emergency care hospital, boosting access

to emergency consultants 24-hours a day, seven days a week.

• The hospital provides a 24/7 specialist acute respiratory admission service directly from

the emergency department. There is also a 24/7 respiratory consultant service at the

hospital.

• The respiratory consultant is present on site 12-hours a day and all new asthma admissions

have a consultant review immediately following admission.

• A respiratory asthma specialist nurse service is present 7-days a week to review all new

patients with asthma, and ensure the provision of all six elements of good practice care.

• The specialist respiratory nurses utilise a proforma which has been designed to ensure that

all parameters of the asthma care bundle are addressed and documented in the patient’s

case notes.

• The team are currently in the process of redesigning this document into an electronic

format which can be then be directly imported into the discharge document to further

improve ongoing communication and documentation of asthma admissions for healthcare

professionals in both secondary and primary care.

• The respiratory specialist nurses update the rolling NACAP asthma audit on a daily basis

for any new patients admitted to the acute respiratory ward in the previous 24 hours.

• The team use the NACAP web tool as an “aide memoire” to highlight any points of good

practice care that have been inadvertently missed during the admission to date; addressing

these before a patient is discharged.




Poole Hospital (Poole Hospital NHS Foundation Trust)

• The respiratory team at Poole Hospital attribute their success in being able to provide the

six elements of good practice care to their joined-up and effective team working.

• The respiratory team consist of three part-time asthma nurse specialists who aim to

review every asthma patient.

• The team are alerted when a patient coded with asthma or shortness of breath are

admitted to the Emergency Department.

• They also walk around the medical wards daily to receive referrals from the wider

respiratory team or ward staff.

• The nurse specialists use their review paperwork as an aide-memoire to prompt them on

the key elements of the discharge care bundle to ensure nothing is forgotten. (appendix

g). The care bundle is also added to their contact sheet to allow for easy data collection for

the NACAP audit.

Every asthma patient the team review is provided with all six elements of good practice care.

• Inhaler technique: the team assess everyone’s ability to use their inhalers and provide

education/aids, as appropriate.

• Maintenance medication reviewed: they assess previous concordance and either prescribe

changes or send recommendations to the team.

• Adherence discussed: the team ask patients about concordance with their inhaled asthma

therapy and discuss ways to achieve full concordance.

• Personalised asthma action plan issued/reviewed: Every inpatient is given an action plan

or has existing one updated.

• Tobacco dependency addressed (if a current smoker): The team discusses smoking

cessation strategies with patients; Nicotine replacement therapy (NRT) is prescribed on the

ward, if appropriate, and the patient is willing.

• Follow-up (community follow-up requested within 2 working days or specialist review

requested within 4 weeks): The team send their review paperwork to the patient’s GP

surgery and ask them to provide a follow-up appointment ideally within 48 hours of

discharge. Patients are also encouraged to contact their GP on discharge for an

appointment.




Appendix A: George Eliot Hospital out–patient proforma

(A full copy of this document can be downloaded for reference here)



https://www.rcplondon.ac.uk/projects/outputs/national-asthma-and-copd-audit-programme-nacap-adult-asthma-secondary-care-good


Appendix B: George Eliot Hospital discharge advice sample

(A copy of this document can be downloaded for reference here)

Discharge Advice – SAMPLE Inhaled Medication Preventer – Fostair 100/6 Nexthaler (PURPLE) – 2 Puffs twice a day Tiotropium Respimat (grey/white)- 2 inhalations once a day Reliever – salbutamol (Blue Inhaler) – 2 puffs when required through the aero chamber spacer Salbutamol 2.5mcg – 1 nebulae through nebuliser if required in an emergency- a maximum of two then must attend A&E department Please record peak flow twice daily: Must contact GP urgently if peak flow falls below…. litres per min (60% of personal best) and does not rise after using reliever inhaler Must seek urgent medical help if

• Increased Shortness of breath

• Wheezing

• Chest Tightness

• Cough

• Unable to speak in full sentences,

• Using reliever inhaler more frequently or is less effective.

To keep see GP for initial follow-up within two working days of discharge. Follow –up Asthma review appointment has been arranged for… DATE… on Elizabeth ward Respiratory room at…TIME…with Asthma Clinical Nurse Specialist. Signed Date





Appendix C: St Mary’s Hospital asthma discharge bundle

Template within each assessment: Asthma Audit to be completed on confirmation of coding: Smoking Status: never/ex/current/ex & current vape/never & current vape/not recorded. Acute Observations on admission: Heart rate: Respiratory rate: Spo2: PEFR: Following admission: 1st recorded PEFR: Date/Time. Best PEFR prior to admission: Respiratory Specialist review: yes/no. Date/Time. Oxygen prescribed/administered: yes/no. Date/Time. Corticosteriods (PO/IV) prescribed/administered: yes/no. Date/Time. SABA administered: yes/no. Date/Time. Prescribed ICS at discharge: yes/no. Prescribed OCS: yes/no. Previous 2 courses of OCS in last 12months: Referral for Asthma follow up made: secondary care/specialist community respiratory/primary. Discharge Care Bundle complete: yes/no.




Appendix D: Lister Hospital asthma discharge care bundle






Appendix E: Lister Hospital asthma discharge bundle


Y/N Smoking Cessation: Ex/Never

Y/N

Adherence discussed Y/N

Current PEF:

PEF Diary given

Triggers discussed

Stand By Medication:

As TTO Has Already

Ask GP NA

Inhaler Tech checked: YES/NO

Sign Time

PAAP:

Given/Declined/Has already

Copy sent to GP: YES/NO

Follow Up:

ASTHMA Discharge Care Bundle (please tick/ci rcle)

Medication discussed

PEF Best/Predicted:

Smoker: Refer/Declined/Self-refer

NRT discussed: YES/NO

NRT agreed and started: YES/NO

GP/HOSP 48hrs

CNS OPA 4/52 Cons OPA___/52

Name Date

Spacer Required:

Change of device: YES/NO

Unable to check:





Appendix F: Manchester Royal Infirmary adult asthma inpatient assessment sheet






Appendix G: Poole Hospital (Poole Hospital NHS Foundation Trust) In-patient

asthma review new patient





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