Confi dential Enquiry report May 2014

Why asthma still killsThe National Review of Asthma Deaths (NRAD)

Commissioned by:

ISBN 978-1-86016-531-3eISBN 978-1-86016-532-0

Royal College of Physicians11 St Andrews Place, Regent’s ParkLondon NW1 4LE

Clinical Effectiveness and Evaluation Unit

Tel: +44 (0)20 3075 1551Fax: +44 (0)20 7487 3988Email: nrad@rcplondon.ac.uk

www.rcplondon.ac.uk/nrad

Why

asthma

stillkillsThe

NationalReview

ofAsthma

Deaths(N

RAD)Confi dentialEnquiry

report2014RoyalCollege

ofPhysicians

NRAD_report_A4_AW.indd 1 22/04/2014 16:50

Supported  by:  

 Eastern  Region  Confidential    Enquiry  of  Asthma  Deaths  

NRAD_report_A4_AW.indd 2 22/04/2014 16:50

Why asthma still killsThe National Review of Asthma Deaths (NRAD)Confidential Enquiry report (May 2014)

Report prepared by:Dr Mark L Levy NRAD clinical lead, Royal College of Physicians (RCP)Rachael Andrews NRAD programme coordinator, Royal College of Physicians (RCP)Rhona Buckingham Operations director, Clinical Effectiveness and Evaluation Unit (CEEU), Royal College of Physicians (RCP)Hannah Evans Medical statistician, Royal College of Physicians (RCP)Caia Francis Senior lecturer in adult nursing, University of the West of England, and former chair, respiratory forum,

Royal College of Nursing (RCN)Rosie Houston NRAD programme manager, Royal College of Physicians (RCP) (until February 2013)Derek Lowe Medical statistician, Royal College of Physicians (RCP)Dr Shuaib Nasser Consultant allergist and respiratory physician; British Society for Allergy and Clinical Immunology (BSACI);

Eastern Region Confidential Enquiry of Asthma DeathsDr James Y Paton Reader in paediatric respiratory medicine, Royal College of Paediatrics and Child Health (RCPCH)Navin Puri Programme manager for respiratory medicine (asthma and lung cancer), Royal College of Physicians (RCP)Dr Kevin Stewart Clinical director, Clinical Effectiveness and Evaluation Unit (CEEU), Royal College of Physicians (RCP)Professor Mike Thomas Professor of primary care research, University of Southampton; Primary Care Respiratory Society UK

(PCRS-UK)

The National Review of Asthma Deaths (NRAD)The National Review of Asthma Deaths (NRAD) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalfof NHS England, NHS Wales, the Health and Social Care Division of the Scottish Government, and the Northern Ireland Department ofHealth, Social Services and Public Safety (DHSSPS). The NRAD is delivered by the Clinical Effectiveness and Evaluation Unit (CEEU) ofthe Clinical Standards Department at the Royal College of Physicians (RCP).

Healthcare Quality Improvement Partnership (HQIP) and the Clinical Outcome Review Programmes (CORP)The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the RoyalCollege of Nursing (RCN) and National Voices. HQIP’s aim is to increase the impact that clinical audit has on healthcare quality andstimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy-makers to learn from adverseevents and other relevant data.

The Royal College of Physicians (RCP)The Royal College of Physicians (RCP) plays a leading role in the delivery of high-quality patient care by setting standards of medicalpractice and promoting clinical excellence. It provides physicians in over 30 medical specialties with education, training and supportthroughout their careers. As an independent charity representing more than 29,000 fellows and members worldwide, it advises and workswith government, patients, allied healthcare professionals and the public to improve health and healthcare.

Citation for this report: Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) ConfidentialEnquiry report. London: RCP, 2014.

CopyrightAll rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium byelectronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission ofthe copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should beaddressed to the publisher.

Copyright © Healthcare Quality Improvement Partnership 2014

Published May 2014

ISBN 978-1-86016-531-3eISBN 978-1-86016-532-0

Royal College of Physicians11 St Andrews PlaceRegent’s ParkLondon NW1 4LE

www.rcplondon.ac.uk Registered Charity No 210508

Typeset by Cambrian Typesetters, Camberley, SurreyPrinted by The Marstan Press Limited, Bexleyheath, Kent

NRAD Prelims 22/4/14 10:14 Page ii

Foreword

Why asthma still kills

It is a great honour to be asked to write the foreword to this report of the National Review of AsthmaDeaths (NRAD) Confidential Enquiry. It represents an immense amount of work, expertly led, executedwith immense attention to detail and involving very large numbers of people freely offering their time toensure the validity of the results.

When the establishment of a confidential enquiry was being considered 3–4 years ago, concern wasexpressed that it may not tell us anything new, and that previous local audits over three or four decadeshad shown depressingly similar findings. Some of the findings reported here are undoubtedly new, somehave been emphasised for over 40 years; however, they are highlighted now, at a time when wepotentially have new systems to address them (eg computerised prescribing), and some results shouldunequivocally lead to a shake-up, more training and monitoring, and an end to the complacency that hasarisen regarding this common condition.

When I first became involved in trying to improve care for those with asthma, there were no guidelines,less choice of medications, very few nurse specialists and little information or support available for thosewith the condition. Much has improved since then but, as this report shows, complacency must betackled. The very heterogeneity of the condition may have contributed to the complacency; however, asthe report shows, it is not just those with severe asthma who die. Whilst one appreciates the diversity ofmedical conditions looked after in primary care, and indeed the diversity of respiratory illnesses lookedafter by chest physicians and paediatricians, some of our failings with regards to asthma care represent ageneral failing to change systems and approaches to accommodate the new health burdens, which are nolonger acute, but long term. If our patients do not always take medication as we advise, is that their faultor our failure to involve them in a process of shared decision making? If the patient fails to attend forreview or to collect a repeat prescription, is it because our processes, methods of follow-up or theirconvenience was suboptimal, or indeed was it the quality of the consultation and the expertiseexperienced that failed to impress? Our continued failure to provide meaningful support as patients self-manage their condition needs to be rectified, and where this needs to be modified to address issues ofliteracy or psychological comorbidity, we need to do so to ensure that good care is equally available to all.

As you read this report, do not forget that it concerns people who have died, many needlessly and manyprematurely, leaving anguish and heartbreak for their loved ones. The best result from this report wouldbe that its recommendations are implemented and a further review of asthma deaths will not berequired, because fewer people die from the disease.

Martyn R PartridgeProfessor of respiratory medicine, Imperial College London

© Healthcare Quality Improvement Partnership 2014

NRAD Prelims 22/4/14 10:14 Page vii

Who is this report for?

This report is intended for use by a wide range of audiences, including:• NHS service managers• pharmacists• primary healthcare settings: GP practices, practice nurses, out-of-hours services, first responders,

paramedics• secondary healthcare settings: hospitals, urgent care centres (UCCs), emergency departments

(accident and emergency)• patients and carers• policy-makers: health departments of England, Northern Ireland, Scotland and Wales• commissioners• professional and patient organisations: royal colleges, specialist societies and organisations

representing patients.

© Healthcare Quality Improvement Partnership 2014

NRAD Prelims 22/4/14 10:14 Page viii

Executive summary

Advancements in drug treatments, applied research and the development of evidence-based clinicalguidelines have contributed to the reduction of deaths from asthma over the past 50 years.

Previous confidential enquiries have suggested that avoidable factors play a part in as many as three-quarters of cases of asthma death. These studies have often been small, conducted locally and undertakenat a considerable time after death. The National Review of Asthma Deaths (NRAD), reported here, is thefirst national investigation of asthma deaths in the UK and the largest study worldwide to date. Work onthe NRAD was undertaken over a 3-year period and was one element of the Department of Health inEngland’s Respiratory Programme. The primary aim of the NRAD was to understand the circumstancessurrounding asthma deaths in the UK in order to identify avoidable factors and make recommendationsto improve care and reduce the number of deaths.

Asthma deaths occurring between February 2012 and January 2013 were identified through the Office forNational Statistics (ONS) for England and Wales, the Northern Ireland Statistics and Research Agency(NISRA) and the National Records of Scotland (NRS). Extensive information about each death was soughtfrom multiple sources, including primary, secondary and tertiary care, as well as ambulance, paramedic andout-of-hours care providers. 374 local coordinators were appointed in 297 hospitals across the NHS tocollect and submit information to the project team, and 174 expert clinical assessors were recruited fromprimary, secondary and tertiary care throughout the UK to join expert panels that reviewed data. Eachassessor participated in one or more expert panels, during which all information gathered on each death,including post-mortem reports, was reviewed by two assessors in detail, and this was followed by discussionand a consensus agreement of avoidable factors and recommendations by the whole panel.

Data were available for analysis on 195 people who were thought to have died from asthma during thereview period and the key findings relate to this group. Denominators vary according to where data weremissing.

Key findings

Use of NHS services

1 During the final attack of asthma, 87 (45%) of the 195 people were known to have died withoutseeking medical assistance or before emergency medical care could be provided.

2 The majority of people who died from asthma (112, 57%) were not recorded as being under specialistsupervision during the 12 months prior to death. Only 83 (43%) were managed in secondary ortertiary care during this period.

© Healthcare Quality Improvement Partnership 2014

NRAD Prelims 22/4/14 10:14 Page ix

3 There was a history of previous hospital admission for asthma in 47% (90 of 190).4 Nineteen (10%) of the 195 died within 28 days of discharge from hospital after treatment for asthma.5 At least 40 (21%) of the 195 people who died had attended a hospital emergency department with

asthma at least once in the previous year and, of these, 23 had attended twice or more.

Medical and professional care

1 Personal asthma action plans (PAAPs), acknowledged to improve asthma care, were known to beprovided to only 44 (23%) of the 195 people who died from asthma.

2 There was no evidence that an asthma review had taken place in general practice in the last year beforedeath for 84 (43%) of the 195 people who died.

3 Exacerbating factors, or triggers, were documented in the records of almost half (95) of patients; theyincluded drugs, viral infections and allergy. A trigger was not documented in the other half.

4 Of 155 patients for whom severity could be estimated, 61 (39%) appeared to have severe asthma.Fourteen (9%) were being treated for mild asthma and 76 (49%) for moderate asthma. It is likely thatmany patients who were treated as having mild or moderate asthma had poorly controlledundertreated asthma, rather than truly mild or moderate disease.

5 The expert panels identified factors that could have avoided death in relation to the healthprofessional’s implementation of asthma guidelines in 89 (46%) of the 195 deaths, including lack ofspecific asthma expertise in 34 (17%) and lack of knowledge of the UK asthma guidelines in 48 (25%).

Prescribing and medicines use

1 There was evidence of excessive prescribing of reliever medication. Among 189 patients who were onshort-acting relievers at the time of death, the number of prescriptions was known for 165, and 65 ofthese (39%) had been prescribed more than 12 short-acting reliever inhalers in the year before theydied, while six (4%) had been prescribed more than 50 reliever inhalers. Those prescribed more than12 reliever inhalers were likely to have had poorly controlled asthma.

2 There was evidence of under-prescribing of preventer medication. To comply with recommendations,most patients would usually need at least 12 preventer prescriptions per year. Among 168 patients onpreventer inhalers at the time of death, either as stand-alone or in combination, the number ofprescriptions was known for 128, and 49 of these (38%) were known to have been issued with fewerthan four and 103 (80%) issued with fewer than 12 preventer inhalers in the previous year.

3 There was evidence of inappropriate prescribing of long-acting beta agonist (LABA) bronchodilatorinhalers. From available data, 27 (14%) of those who died were prescribed a single-component LABAbronchodilator at the time of death. At least five (3%) patients were on LABA monotherapy withoutinhaled corticosteroid preventer treatment.

Patient factors and perception of risk of poor control

1 The expert panels identified factors that could have avoided the death related to patients, their familiesand the environment in 126 (65%) of those who died. These included current tobacco smoking in 37 (19%), exposure to second-hand smoke in the home, non-adherence to medical advice and non-attendance at review appointments.

2 Particularly in children and young people, poor recognition of risk of adverse outcome was found tobe an important avoidable factor in 7/10 (70%) children and 15/18 (83%) young people in primarycare, and in 2/7 (29%) children and 3/9 (33%) young people in secondary care.

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page x

3 The median age at the time of the initial diagnosis of asthma was 37 years. Most people who died, andfor whom this information was available, were diagnosed in adulthood, with 70/102 (69%) diagnosedafter the age of 15 years.

4 Psychosocial factors contributing to the risk of asthma death and its perception were identified bypanels in 51 (26%) of those who died, and included depression and mental health issues in 32 (16%)and substance misuse in 12 (6%).

Key recommendations

Organisation of NHS services

1 Every NHS hospital and general practice should have a designated, named clinical lead for asthmaservices, responsible for formal training in the management of acute asthma.

2 Patients with asthma must be referred to a specialist asthma service if they have required morethan two courses of systemic corticosteroids, oral or injected, in the previous 12 months or require management using British Thoracic Society (BTS) stepwise treatment 4 or 5 to achievecontrol.1

3 Follow-up arrangements must be made after every attendance at an emergency department or out-of-hours service for an asthma attack. Secondary care follow-up should be arranged after every hospitaladmission for asthma, and for patients who have attended the emergency department two or moretimes with an asthma attack in the previous 12 months.

4 A standard national asthma template should be developed to facilitate a structured, thorough asthmareview. This should improve the documentation of reviews in medical records and form the basis oflocal audit of asthma care.

5 Electronic surveillance of prescribing in primary care should be introduced as a matter of urgency toalert clinicians to patients being prescribed excessive quantities of short-acting reliever inhalers, or toofew preventer inhalers.

6 A national ongoing audit of asthma should be established, which would help clinicians, commissionersand patient organisations to work together to improve asthma care.

Medical and professional care

1 All people with asthma should be provided with written guidance in the form of a personal asthmaaction plan (PAAP) that details their own triggers and current treatment, and specifies how to preventrelapse and when and how to seek help in an emergency.

2 People with asthma should have a structured review by a healthcare professional with specialisttraining in asthma, at least annually. People at high risk of severe asthma attacks should be monitoredmore closely, ensuring that their personal asthma action plans (PAAPs) are reviewed and updated ateach review.

3 Factors that trigger or exacerbate asthma must be elicited routinely and documented in the medicalrecords and personal asthma action plans (PAAPs) of all people with asthma, so that measures can betaken to reduce their impact.

4 An assessment of recent asthma control should be undertaken at every asthma review. Where loss ofcontrol is identified, immediate action is required, including escalation of responsibility, treatmentchange and arrangements for follow-up.

5 Health professionals must be aware of the factors that increase the risk of asthma attacks and death,including the significance of concurrent psychological and mental health issues.

© Healthcare Quality Improvement Partnership 2014

Executive summary

NRAD Prelims 22/4/14 10:14 Page xi

Prescribing and medicines use

1 All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in theprevious 12 months should be invited for urgent review of their asthma control, with the aim ofimproving their asthma through education and change of treatment if required.

2 An assessment of inhaler technique to ensure effectiveness should be routinely undertaken andformally documented at annual review, and also checked by the pharmacist when a new device isdispensed.

3 Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthmacontrol and should be continually monitored.

4 The use of combination inhalers should be encouraged. Where long-acting beta agonist (LABA)bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaledcorticosteroid in a single combination inhaler.

Patient factors and perception of risk

1 Patient self-management should be encouraged to reflect their known triggers, eg increasingmedication before the start of the hay-fever season, avoiding non-steroidal anti-inflammatory drugs orby the early use of oral corticosteroids with viral- or allergic-induced exacerbations.

2 A history of smoking and/or exposure to second-hand smoke should be documented in the medicalrecords of all people with asthma. Current smokers should be offered referral to a smoking-cessationservice.

3 Parents and children, and those who care for or teach them, should be educated about managingasthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthmamedications, recognising when asthma is not controlled and knowing when and how to seekemergency advice.

4 Efforts to minimise exposure to allergens and second-hand smoke should be emphasised, especially inyoung people with asthma.

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page xii

Reco

mm

enda

tion

s m

atri

x

Reco

mm

enda

tion

NH

S Ph

arm

acis

tsPr

imar

y Se

cond

ary

Pati

ents

Po

licy-

mak

ers:

Com

mis

sion

ers

Prof

essi

onal

serv

ice

heal

thca

rehe

alth

care

and

heal

than

d pa

tien

t

man

ager

sse

ttin

gs:

sett

ings

: ca

rers

depa

rtm

ents

orga

nisa

tion

s:

GP

prac

tice

s,ho

spit

als,

of

Eng

land

, ro

yal c

olle

ges,

prac

tice

nur

ses,

urge

nt c

are

Nor

ther

n sp

ecia

list

out-

of-h

ours

cent

res

(UC

Cs)

, Ir

elan

d,

soci

etie

s an

d

serv

ices

, fir

stem

erge

ncy

Scot

land

and

orga

nisa

tion

s

resp

onde

rs,

depa

rtm

ents

Wal

esre

pres

enti

ng

para

med

ics

(acc

iden

t an

dpa

tien

ts

emer

genc

y)

Org

anis

atio

n of

NH

S se

rvic

es

Ever

y N

HS

hosp

ital

and

ge

nera

l pra

ctic

e sh

ould

ha

ve a

des

igna

ted,

nam

ed

clin

ical

lead

for a

sthm

a P

PP

PP

serv

ices

, res

pons

ible

for

form

al tr

aini

ng in

the

man

agem

ent o

f acu

te

asth

ma

Pati

ents

wit

h as

thm

a m

ust

be re

ferr

ed to

a s

peci

alis

t as

thm

a se

rvic

e if

they

hav

e re

quire

d m

ore

than

two

cour

ses

of s

yste

mic

co

rtic

oste

roid

s, o

ral o

r P

PP

inje

cted

, in

the

prev

ious

12

mon

ths

or re

quire

m

anag

emen

t usi

ng

Brit

ish

Thor

acic

Soc

iety

(B

TS) s

tepw

ise

trea

tmen

t 4

or 5

to a

chie

ve c

ontr

ol1

© Healthcare Quality Improvement Partnership 2014

NRAD Prelims 22/4/14 10:14 Page xiii

Reco

mm

enda

tion

NH

S Ph

arm

acis

tsPr

imar

y Se

cond

ary

Pati

ents

Po

licy-

mak

ers:

Com

mis

sion

ers

Prof

essi

onal

serv

ice

heal

thca

rehe

alth

care

and

heal

than

d pa

tien

t

man

ager

sse

ttin

gs:

sett

ings

: ca

rers

depa

rtm

ents

orga

nisa

tion

s:

GP

prac

tice

s,ho

spit

als,

of

Eng

land

, ro

yal c

olle

ges,

prac

tice

nur

ses,

urge

nt c

are

Nor

ther

n sp

ecia

list

out-

of-h

ours

cent

res

(UC

Cs)

, Ir

elan

d,

soci

etie

s an

d

serv

ices

, fir

stem

erge

ncy

Scot

land

and

orga

nisa

tion

s

resp

onde

rs,

depa

rtm

ents

Wal

esre

pres

enti

ng

para

med

ics

(acc

iden

t an

dpa

tien

ts

emer

genc

y)

Follo

w-u

p ar

rang

emen

ts

mus

t be

mad

e af

ter e

very

at

tend

ance

at a

n em

erge

ncy

depa

rtm

ent o

r out

-of-

hour

sse

rvic

e fo

r an

asth

ma

atta

ck.

Seco

ndar

y ca

re fo

llow

-up

shou

ld b

e ar

rang

ed a

fter

P

PP

Pev

ery

hosp

ital

adm

issi

on fo

r as

thm

a, a

nd fo

r pat

ient

s w

ho h

ave

atte

nded

the

emer

genc

y de

part

men

t tw

o or

mor

e ti

mes

wit

h an

as

thm

a at

tack

in th

e pr

evio

us 1

2 m

onth

s

A s

tand

ard

nati

onal

ast

hma

tem

plat

e sh

ould

be

deve

lope

d to

faci

litat

e a

stru

ctur

ed, t

horo

ugh

asth

ma

revi

ew. T

his

shou

ldP

PP

Pim

prov

e th

e do

cum

enta

tion

of

revi

ews

in m

edic

al

reco

rds

and

form

the

basi

s of

loca

l aud

it o

f ast

hma

care

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page xiv

© Healthcare Quality Improvement Partnership 2014

Elec

tron

ic s

urve

illan

ce o

f pr

escr

ibin

g in

prim

ary

care

sh

ould

be

intr

oduc

ed a

s a

mat

ter o

f urg

ency

to a

lert

cl

inic

ians

to p

atie

nts

bein

g P

PP

Ppr

escr

ibed

exc

essi

ve

quan

titi

es o

f sho

rt-a

ctin

g re

lieve

r inh

aler

s, o

r too

few

pr

even

ter i

nhal

ers

A n

atio

nal o

ngoi

ng a

udit

of

ast

hma

shou

ld b

e es

tabl

ishe

d, w

hich

wou

ld

help

clin

icia

ns,

Pco

mm

issi

oner

s an

d pa

tien

t or

gani

sati

ons

to w

ork

toge

ther

to im

prov

e as

thm

a ca

re

Ther

e is

a n

eed

for i

mpr

oved

gu

idan

ce fo

r doc

tors

co

mpl

etin

g M

edic

al

PP

PP

Cert

ific

ates

of C

ause

of

Dea

th (M

CC

Ds)

In a

ll ca

ses

whe

re a

sthm

a is

co

nsid

ered

to b

e th

e ca

use

of d

eath

, the

re s

houl

d be

a

stru

ctur

ed lo

cal c

ritic

al

inci

dent

revi

ew in

prim

ary

PP

PP

PP

Pca

re (t

o in

clud

e se

cond

ary

care

if a

ppro

pria

te) w

ith

help

from

a c

linic

ian

wit

h re

leva

nt e

xper

tise

Recommendations matrix

NRAD Prelims 22/4/14 10:14 Page xv

Reco

mm

enda

tion

NH

S Ph

arm

acis

tsPr

imar

y Se

cond

ary

Pati

ents

Po

licy-

mak

ers:

Com

mis

sion

ers

Prof

essi

onal

serv

ice

heal

thca

rehe

alth

care

and

heal

than

d pa

tien

t

man

ager

sse

ttin

gs:

sett

ings

: ca

rers

depa

rtm

ents

orga

nisa

tion

s:

GP

prac

tice

s,ho

spit

als,

of

Eng

land

, ro

yal c

olle

ges,

prac

tice

nur

ses,

urge

nt c

are

Nor

ther

n sp

ecia

list

out-

of-h

ours

cent

res

(UC

Cs)

, Ir

elan

d,

soci

etie

s an

d

serv

ices

, fir

stem

erge

ncy

Scot

land

and

orga

nisa

tion

s

resp

onde

rs,

depa

rtm

ents

Wal

esre

pres

enti

ng

para

med

ics

(acc

iden

t an

dpa

tien

ts

emer

genc

y)

Med

ical

and

pro

fess

iona

l car

e

All

peop

le w

ith

asth

ma

shou

ld b

e pr

ovid

ed w

ith

writ

ten

guid

ance

in th

e fo

rm o

f a p

erso

nal a

sthm

a ac

tion

pla

n (P

AA

P) th

at

PP

PP

Pde

tails

thei

r ow

n tr

igge

rs

and

curr

ent t

reat

men

t, an

d sp

ecif

ies

how

to p

reve

nt

rela

pse

and

whe

n an

d ho

w

to s

eek

help

in a

n em

erge

ncy

Peop

le w

ith

asth

ma

shou

ld

have

a s

truc

ture

d re

view

by

a he

alth

care

pro

fess

iona

l w

ith

spec

ialis

t tra

inin

g in

as

thm

a, a

t lea

st a

nnua

lly.

Peop

le a

t hig

h ris

k of

sev

ere

PP

Pas

thm

a at

tack

s sh

ould

be

mon

itor

ed m

ore

clos

ely,

en

surin

g th

at th

eir p

erso

nal

asth

ma

acti

on p

lans

(PA

APs

) ar

e re

view

ed a

nd u

pdat

ed

at e

ach

revi

ew

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page xvi

Fact

ors

that

trig

ger o

r ex

acer

bate

ast

hma

mus

t be

elic

ited

rout

inel

y an

d do

cum

ente

d in

the

med

ical

re

cord

s an

d pe

rson

al a

sthm

a P

Pac

tion

pla

ns (P

AA

Ps) o

f all

peop

le w

ith

asth

ma,

so

that

m

easu

res

can

be ta

ken

to

redu

ce th

eir i

mpa

ct

An

asse

ssm

ent o

f rec

ent

asth

ma

cont

rol s

houl

d be

un

dert

aken

at e

very

ast

hma

revi

ew. W

here

loss

of c

ontr

ol

is id

enti

fied

, im

med

iate

P

PP

Pac

tion

is re

quire

d, in

clud

ing

esca

lati

on o

f res

pons

ibili

ty,

trea

tmen

t cha

nge

and

arra

ngem

ents

for f

ollo

w-u

p

Hea

lth

prof

essi

onal

s m

ust b

e aw

are

of th

e fe

atur

es th

at

incr

ease

the

risk

of a

sthm

a at

tack

s an

d de

ath,

incl

udin

g P

PP

Pth

e si

gnif

ican

ce o

f co

ncur

rent

psy

chol

ogic

al

and

men

tal h

ealt

h is

sues

© Healthcare Quality Improvement Partnership 2014

Recommendations matrix

NRAD Prelims 22/4/14 10:14 Page xvii

Reco

mm

enda

tion

NH

S Ph

arm

acis

tsPr

imar

y Se

cond

ary

Pati

ents

Po

licy-

mak

ers:

Com

mis

sion

ers

Prof

essi

onal

serv

ice

heal

thca

rehe

alth

care

and

heal

than

d pa

tien

t

man

ager

sse

ttin

gs:

sett

ings

: ca

rers

depa

rtm

ents

orga

nisa

tion

s:

GP

prac

tice

s,ho

spit

als,

of

Eng

land

, ro

yal c

olle

ges,

prac

tice

nur

ses,

urge

nt c

are

Nor

ther

n sp

ecia

list

out-

of-h

ours

cent

res

(UC

Cs)

, Ir

elan

d,

soci

etie

s an

d

serv

ices

, fir

stem

erge

ncy

Scot

land

and

orga

nisa

tion

s

resp

onde

rs,

depa

rtm

ents

Wal

esre

pres

enti

ng

para

med

ics

(acc

iden

t an

dpa

tien

ts

emer

genc

y)

Pres

crib

ing

and

med

icin

es u

se

All

asth

ma

pati

ents

who

ha

ve b

een

pres

crib

ed m

ore

than

12

shor

t-ac

ting

re

lieve

r inh

aler

s in

the

prev

ious

12

mon

ths

shou

ld

be in

vite

d fo

r urg

ent r

evie

w

PP

PP

PP

Pof

thei

r ast

hma

cont

rol,

wit

h th

e ai

m o

f im

prov

ing

thei

r ast

hma

thro

ugh

educ

atio

n an

d ch

ange

of

trea

tmen

t if r

equi

red

An

asse

ssm

ent o

f inh

aler

te

chni

que

to e

nsur

e ef

fect

iven

ess

shou

ld b

e ro

utin

ely

unde

rtak

en a

nd

form

ally

doc

umen

ted

at

PP

Pan

nual

revi

ew, a

nd a

lso

chec

ked

by th

e ph

arm

acis

t w

hen

a ne

w d

evic

e is

di

spen

sed

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page xviii

Non

-adh

eren

ce to

pre

vent

er

inha

led

cort

icos

tero

ids

is

asso

ciat

ed w

ith

incr

ease

d P

PP

risk

of p

oor a

sthm

a co

ntro

l an

d sh

ould

be

cont

inua

lly

mon

itor

ed

The

use

of c

ombi

nati

on

inha

lers

sho

uld

be

enco

urag

ed. W

here

long

-ac

ting

bet

a ag

onis

t (LA

BA

) br

onch

odila

tors

are

P

PP

Ppr

escr

ibed

for p

eopl

e w

ith

asth

ma,

they

sho

uld

be

pres

crib

ed w

ith

an in

hale

d co

rtic

oste

roid

in a

sin

gle

com

bina

tion

inha

ler

The

use

of p

atie

nt-h

eld

‘res

cue’

med

icat

ions

in

clud

ing

oral

cor

tico

ster

oids

an

d se

lf-a

dmin

iste

red

adre

nalin

e, a

s pa

rt o

f a

writ

ten

self

-man

agem

ent

PP

PP

PP

plan

, sho

uld

be c

onsi

dere

d fo

r all

pati

ents

who

hav

e

had

a lif

e-th

reat

enin

g

asth

ma

atta

ck o

r a n

ear-

fa

tal e

piso

de

© Healthcare Quality Improvement Partnership 2014

Recommendations matrix

NRAD Prelims 22/4/14 10:14 Page xix

Reco

mm

enda

tion

NH

S Ph

arm

acis

tsPr

imar

y Se

cond

ary

Pati

ents

Po

licy-

mak

ers:

Com

mis

sion

ers

Prof

essi

onal

serv

ice

heal

thca

rehe

alth

care

and

heal

than

d pa

tien

t

man

ager

sse

ttin

gs:

sett

ings

: ca

rers

depa

rtm

ents

orga

nisa

tion

s:

GP

prac

tice

s,ho

spit

als,

of

Eng

land

, ro

yal c

olle

ges,

prac

tice

nur

ses,

urge

nt c

are

Nor

ther

n sp

ecia

list

out-

of-h

ours

cent

res

(UC

Cs)

, Ir

elan

d,

soci

etie

s an

d

serv

ices

, fir

stem

erge

ncy

Scot

land

and

orga

nisa

tion

s

resp

onde

rs,

depa

rtm

ents

Wal

esre

pres

enti

ng

para

med

ics

(acc

iden

t an

dpa

tien

ts

emer

genc

y)

Pati

ent

fact

ors

and

perc

epti

on o

f ri

sk

Pati

ent s

elf-

man

agem

ent

shou

ld b

e en

cour

aged

to

refl

ect t

heir

know

n tr

igge

rs,

eg in

crea

sing

med

icat

ion

befo

re th

e st

art o

f the

hay

-fe

ver s

easo

n, a

void

ing

non-

PP

PP

Pst

eroi

dal a

nti-i

nfla

mm

ator

y dr

ugs

or b

y th

e ea

rly u

se o

f or

al c

orti

cost

eroi

ds w

ith

vira

l- or

alle

rgic

-indu

ced

exac

erba

tion

s

A h

isto

ry o

f sm

okin

g an

d/or

ex

posu

re to

sec

ond-

hand

sm

oke

shou

ld b

e do

cum

ente

din

the

med

ical

reco

rds

of a

ll P

PP

PP

peop

le w

ith

asth

ma.

Cur

rent

sm

oker

s sh

ould

be

offe

red

refe

rral

to a

sm

okin

g-ce

ssat

ion

serv

ice

© Healthcare Quality Improvement Partnership 2014

Why asthma still kills

NRAD Prelims 22/4/14 10:14 Page xx

Pare

nts

and

child

ren,

and

th

ose

who

car

e fo

r or t

each

th

em, s

houl

d be

edu

cate

d ab

out m

anag

ing

asth

ma.

Th

is s

houl

d in

clud

e em

phas

is P

PP

PP

on ‘h

ow’,

‘why

’ and

‘whe

n’

they

sho

uld

use

thei

r ast

hma

med

icat

ions

, rec

ogni

sing

w

hen

asth

ma

is n

ot

cont

rolle

d an

d kn

owin

g w

hen

and

how

to s

eek

emer

genc

y ad

vice

Effo

rts

to m

inim

ise

expo

sure

to a

llerg

ens

and

seco

nd-h

and

smok

e sh

ould

P

PP

Pbe

em

phas

ised

, esp

ecia

lly

in y

oung

peo

ple

wit

h as

thm

a

Rese

arch

reco

mm

enda

tion

Furt

her r

esea

rch

is re

quire

d to

con

firm

whe

ther

late

-P

Pon

set a

sthm

a is

a ri

sk fa

ctor

fo

r ast

hma

deat

h

© Healthcare Quality Improvement Partnership 2014

Recommendations matrix

NRAD Prelims 22/4/14 10:14 Page xxi

Confi dential Enquiry report May 2014

Why asthma still killsThe National Review of Asthma Deaths (NRAD)

Commissioned by:

ISBN 978-1-86016-531-3eISBN 978-1-86016-532-0

Royal College of Physicians11 St Andrews Place, Regent’s ParkLondon NW1 4LE

Clinical Effectiveness and Evaluation Unit

Tel: +44 (0)20 3075 1551Fax: +44 (0)20 7487 3988Email: nrad@rcplondon.ac.uk

www.rcplondon.ac.uk/nrad

Why asthm

a still kills The National Review

of Asthma D

eaths (NRAD

) Confi dential Enquiry report 2014 Royal College of Physicians

NRAD_report_A4_AW.indd 1 22/04/2014 16:50