Section 4:

The importance of prompt review after an asthma attack

A post-attack review offers the opportunity to assess the patient’s risk status, ask ‘why did this attack happen’ and address issues arising, such as suboptimal therapy, lack of adherence, or poor inhaler technique. It is also an opportunity to identify patients who should be referred for specialist care.

It is sobering to reflect on NRAD’s finding that 10% of people with asthma who died did so within 28 days of being treated in hospital for an asthma attack. NRAD identified potentially avoidable factors in 68% of these patients relating to their discharge from hospital and follow up arrangements: at least 40 (21%) of those who died had attended an emergency department with an asthma attack in the previous year and, of these, 23 people had attended on at least two occasions.1

BTS/SIGN recommends a follow up appointment with the patient’s GP or asthma nurse within two working days of discharge.2 The practice should be informed within 24 hours of discharge from an emergency department or hospital following an asthma attack. Ideally, this communication should be directly with a named individual responsible for asthma care within the practice.2 The practice should have a robust system in place to ensure patients are followed up and do not default.

GINA also recommends follow up takes place within 2 days of discharge to ensure that treatment is continued, asthma symptoms are well controlled and the patient’s lung function reaches their personal best.3

The recently published National Clinical Audit report on adult asthma found that only 31% of patients admitted to hospital for an asthma attack received all elements of good practice care, set out in the British Thoracic Society ‘Asthma Care Bundle’ before discharge.4,5 These elements comprise:

  • Inhaler technique check
  • Maintenance medication review
  • Adherence discussed
  • Personalised asthma action plan issued/reviewed
  • Tobacco dependency addressed (if a current smoker), and
  • Follow up

A post-attack follow up appointment in general practice provides another chance to ensure that all these care processes have taken place.

It may be that your patient has had an asthma attack but not needed to access urgent care. Nonetheless they should be seen within 48 hours of an attack, even if it has apparently resolved. Explain to patients that having one attack makes a second one more likely, and they should book an appointment to see their GP or general practice nurse. Include this instruction in asthma patients’ personalised action plans.6

Practice staff, including receptionists, should also understand the importance of offering an appointment within 48 hours of an asthma attack. Patients treated for an attack – in the practice or elsewhere – need to be given the Read Code H333 (acute asthma exacerbation) and recalled for review.7

Job code: UK/RES-19014e DOP: May 2020

References

  1. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report; 2014. https://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf [Accessed May 2020]
  2. BTS/SIGN British Guideline on the Management of Asthma; 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ [Accessed May 2020]
  3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention; 2019. https://www.ginaasthma.org [Accessed May 2020]
  4. Royal College of Physicians. National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP). Adult asthma clinical audit 2018/19; December 2019. https://www.nacap.org.uk/nacap/welcome.nsf/vwFiles/AA-National-2018-19/$File/Adult+asthma_national+clinical+report_2019.pdf?openelement [Accessed May 2020]
  5. British Thoracic Society. Improving Outcomes in Asthma: Asthma Care Bundle v3; 2016 https://www.brit-thoracic.org.uk/media/70102/bts-asthma-care-bundle-april-2016-v3.pdf [Accessed May 2020]
  6. Asthma UK. Filling in patients’ asthma action plans. https://www.asthma.org.uk/for-professionals/professionals/filling-patients-action-plans/ [Accessed May 2020]
  7. Levy M. Asthma reviews: a new look. Practice Nurse 2020;50(1):30-35