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Audit reveals 'wide variation' in speed of asthma care in emergency departments

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Pressure on accident and emergency departments means they are finding it “challenging” to meet standards for timely treatment for asthma patients, warn the authors of an audit.

They cited a dangerous mix of causal factors, including lack of adequate numbers of nursing and medical staff in A&E to cope with demand, lack of staff education in key areas for staff, delayed discharge and a lack of robust protocols and pathways.

“The ‘big ticket items’ are likely to be a lack of adequate numbers of medical and nursing staff”

Taj Hassan

Joined-up solutions are needed to provide asthma care faster, as emergency departments struggle to meet standards, according to the new audit by the Royal College of Emergency Medicine (RCEM).

The fact that only 25% of A&E departments can administer a nebulised bronchodilator within 10 minutes of arrival is of “great concern”, the college warned.

Meanwhile, most departments only managed to demonstrate giving oxygen on arrival in 19% of their patients and only a third had all of their vital signs recorded on arrival.

The college noted that patients with any recorded abnormal vital signs should have a further complete set of vital signs recorded in the notes within 60 minutes of the first set.

It found a full set of vitals was repeated for 39% of patients but only 13% of departments managed it within the hour. Peak flow was “particularly badly recorded”, with only 21% getting a repeat done.

The college’s new audit report, published today, is based on an audit of 14,043 children and adults with moderate and acute severe asthma presenting to 201 emergency departments.

“It is not enough to say it is busy and there is no scope for improvement”

Taj Hassan

It revealed that many departments are finding it “challenging to adhere” to the time standards set by the British Thoracic Society and RCEM.

The problems probably reflect the increasing demands on A&Es, with higher volumes of patients with increasingly complex health needs, noted the college.

Stretched resources meant time to first assessment and treatment could be delayed and, therefore, re-assessment in a timely fashion was more difficult to achieve, it said in the report.

It highlighted that identifying derangement in vital signs and peak flow early was a very important part of good asthma care, because it guided treatment and, thus, reduced morbidity and mortality.

Among its key recommendations, the report said departments should consider how oxygen was prescribed and ensure that all asthmatics were prescribed it on arrival to maintain saturations of 94-98%, preferably with a β2 agonist if required.

Taj hassan

Taj hassan

Taj Hassan

In addition, A&E departments should consider an education programme for staff to improve vital signs monitoring and conduct regular local audits to ensure compliance with particular focus on timing and peak flow measurement.

Dr Taj Hassan, president of the RCEM, said: “Every 10 seconds someone is having a potentially life threatening asthma attack and, despite remarkable efforts by NHS staff, three people will die of acute asthma every day in the UK.”

He added: “The reasons for the concerning figures are probably multifactorial. The ‘big ticket items’ are likely to be a lack of adequate numbers of medical and nursing staff in EDs to cope with demand, crowding due to exit block compromising care delivery, a lack of robust protocols and pathways to support decision making, and lack of education in key areas for staff.

“There is much that can be learned from departments who do manage to adhere well to these standards and they should be congratulated,” said Dr Hassan.

“Better sharing of working practices is needed,” he noted. “It is not enough to say it is busy and there is no scope for improvement.”

Dr Hassan also emphasised the need for joined up working to improve care.

“The audit shows a regrettable decline in performance, something we must urgently address”

John White

In response, the British Thoracic Society urged clinicians to use its guidance on the diagnosis and management of asthma patients, and its five step care plan to reduce readmission after discharge.

Dr John White, BTS member and consultant respiratory physician at York NHS Foundation Trust, said: “The audit shows a regrettable decline in performance, something we must urgently address.”

He added: “We encourage all emergency departments to adopt the five step care plan or ‘care bundle’ the British Thoracic Society has developed with Asthma UK to reduce future life-threatening asthma attacks and hospital admissions, saving many lives a year across the UK.”

The care bundle covers a set of evidence-based actions including assessing inhaler technique, reviewing medication, providing a written asthma action plan, looking at “trigger” factors like tobacco smoke at home and ensuring a follow-up appointment.

“Preventing readmission by improving ongoing asthma control is an important part of reducing illness from asthma and saving lives,” said Dr White.

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