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January 2020

National audit reveals shocking failings in emergency care for asthma attacks

The first national audit report on care provided to UK patients admitted to hospital with an asthma attack has found shocking failings in the care they received on arrival, and delays in receiving the most fundamental basics of treatment.

The report reveals two immediate areas for improvement – improving the assessment of the severity of the attack ‘at the front door’ and making sure patients received systemic steroids within an hour of arrival.

Only 28% of patients had a PEF measurement of severity within 1 hour of arrival at hospital and more than a quarter, 27%, did not have their PEF recorded at any point during their admission, according to the Royal College of Physicians/Health Quality Improvement Partnership (RCP/HQIP) National Asthma and COPD Audit Programme (NACAP) audit report on adult asthma.

The audit data show that timely administration of systemic steroids was associated with an increased likelihood of a shorter length of hospital stay – but only 31% of patients who received systemic steroids were given them within 1 hour of arrival – although some of these may have been treated as part of pre-hospital care.

The NACAP report also revealed:

  • Personalised asthma action plans (PAAPs) are associated with a reduction in hospital admissions and unscheduled use of medical services – but 59% were discharged without a PAAP or review of their existing plan.
  • More than 10% left hospital without inhaled steroids being initiated (excluding 0.5% patients not prescribed ICS for medical reasons). This means a critical opportunity to reduce the risk of further attacks was missed.
  • A key recommendation of the National Review of Asthma Deaths was that patients who have had more than two courses of systemic steroids in the previous 12 months should be referred for secondary care assessment; 13% of patients who met this criterion were discharged without a referral for hospital follow up in place, and 1% declined referral.

The audit included 10,242 hospital admissions for adults with asthma attacks between November 2018 and March 2019. The first report revealed that 23 (0.2%) of audited patients died during their hospital stay. A further report will be published this year, covering 30- and 90-day mortality and hospital readmission rates.

A breakdown of asthma severity showed 35% of audited patients had moderate acute asthma, 51% had severe acute asthma, and 14% had life-threatening acute asthma. Just over 16% of those with life-threatening asthma and 20% of those with severe acute asthma were not reviewed by a respiratory specialist. Those who were reviewed by a specialist waited between 19.5 and 21.4 hours.

Almost 60% of patients had to wait more than an hour for administration of a beta-2 agonist, and some waited more than 4 hours. More than 34% waited more than four hours for administration of systemic steroids.

Before discharge, only 31% of patients received the six elements of good practice care set out in the British Thoracic Society Asthma Care Bundle, which comprises:

  • Inhaler technique checked
  • Maintenance medication reviewed
  • Adherence discussed
  • PAAP issued/reviewed
  • Tobacco dependency addressed
  • Follow up requested – within 2 working days in the community, and/or specialist review within 4 weeks.

The least frequently provided elements of good care were community follow up requested within 2 working days (34%) and issue/review of PAAP (41%). The most frequently provided elements were inhaler technique checked (59%) and maintenance medication reviewed (70%).

The audit report makes a number of recommendations for hospital providers, including:

  • 90% of patients should be assessed for asthma severity, including PEF measurement, within 1 hour of arrival
  • 90% of patients should receive a respiratory specialist review before discharge
  • 95% of patients who have not been administered systemic steroids as part of pre-hospital care should be administered this treatment with 1 hour of arrival.

The NACAP recommendations for primary care are:

  • To ensure that all asthma patients have a PAAP
  • To identify patients who have had more than two courses of systemic steroids in the last 12 months, or who are poorly controlled at BTS step 4 or 5, for review. Refer to secondary care if options for optimising care are unclear or where there is diagnostic uncertainty
  • To ensure that staff are adequately trained and updated in asthma care.

RCP/HQIP Adult asthma audit report 2019