Paediatric Asthma Bundle Initial Report

To what extent has the implementation of a new paediatric asthma bundle improved care for children age two or older visiting hospital with wheeze?

Project Leads: Felicity Knights and Rebecca Ellerton (Foundation Year 2s) Dr Mark Anderson (Paediatric Consultant)

Background: Every year the Great North Children’s Hospital, Royal Victoria Infirmary (RVI), Newcastle Upon Tyne treats over 23,000 children (1). In the UK it is estimated that approximately 1.1 million children have asthma (2) and between 2011-2012 there were 25,073 children admitted to hospital following an asthma attack (2). With high figures such as these, it is crucial that we regularly assess our performance in the treatment of asthma and wheeze, in order to improve the care we deliver to our patients.

Additionally there has been a Newcastle case review of a seven-year old child with severe brittle asthma who died unexpectedly following several admissions to the Great North Children’s Hospital at the RVI. A number of inconsistencies and omissions were picked up around the discharge process following these which led to recommendations for education and standardisation around discharge of similar cases.

This finding echoes the report of the Great North Children’s Hospital’s latest asthma audit which was undertaken in line with British Thoracic Society’s recommendations in November 2014. It found the following: ‘Treatment of asthma and wheeze in ward 6 is in line with SIGN guidance, but background history, discharge process and follow up fall below the SIGN guidelines standard. Although during the audit period there were no wheeze related admissions to PICU, poor discharge planning and follow up could lead to more severe asthma exacerbations and poorer prognosis for children with recurrent wheeze. We must be proactive in order to provide excellent clinical care, focussed on inpatient care, follow up and patient education.’

Following multiple discussions and gathering of a range of stakeholder views, the decision was made to implement a new care bundle for paediatric asthma. A care bundle is a structured way of improving the process of care leading to an improvement in patient outcomes. It is a small, straightforward set of evidence-based clinical interventions or actions, which when performed reliably improve patient outcomes. The bundle resembles a list, but is a cohesive unit where all elements must be completed to achieve the best outcomes. The value of care bundles for a number of treatment areas has been demonstrated in a UK hospital setting; where a fall of 18.5 points in the hospital standardised mortality occurred following bundle implementation for 13 diagnoses (3).

SIGN Definitions and Advice Regarding Asthma: The SIGN asthma documentation defines asthma as “the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction” (4). However the most common clinical presentation is symptom onset associated with a viral upper respiratory tract infection in pre-school age children, of which a minority go on to develop interval symptoms and classic atopic asthma (4).

Figures demonstrate that male sex increases the risk for asthma before puberty (4) with a higher prevalence during childhood in males, with a ratio of 65% male to 35% female (3). There is also increased risk of childhood wheeze and persistent asthma in households where parents smoke (4). Any exposure to smoking, direct or passive, “adversely affects quality of life, lung function, need for rescue medications for acute episodes of asthma and long term control with ICS” (4). As a result of the above, we can conclude that it is vital when treating a child with wheeze to document sex, any previous wheezing episodes and family smoking status.

Sign provides clear guidelines outlining the expected investigations and management of children presenting with wheeze. In particular there has been investigation of asthma deaths in children, concluding that many of these patients “had received inadequate treatment with ICS or steroid tablets and/or inadequate objective monitoring of their asthma. Follow up was inadequate in some and others should have been referred earlier for specialist advice.

There was widespread underuse of written management plans.”(4)

In summary, the SIGN guidelines advise (4): 

Reserving chest x-rays for use in patients with severe asthma or signs suggesting a different diagnosis

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Only prescribing inhalers after patients/parents have had sufficient training in device use, and demonstrated adequate technique

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Any child with oxygen saturations less that 94% should receive high flow oxygen

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Steroids should be used early

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Patients should receive a written asthma management plan

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There should be consideration of preventer treatment requirements

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Primary care follow up should be arranged within 48hours of discharge

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Referral to paediatric respiratory specialist in patients with any features of a life-threatening exacerbation

Description of Bundle: At present the bundle contains the following: 

Asthma assessment and management flowsheet (for the doctors)

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Asthma management and discharge checklist (for doctors which doubles up for data collection)

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Discharge checklist for parents/patients

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‘Token’ to remind children over the age of 6 to collect a Peak Flow from nurses

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Information leaflets covering asthma, viral induced wheeze, inhalers and spacers

Objectives: 1. To report data based on a National BTS (British Thoracic Society) Audit design, on children >2 years admitted to Newcastle Hospitals Trust with asthma/wheeze 2. To compare this data with 2014 data from the trust and National Standards of BTS/SIGN (Scottish Intercollegiate Guidelines Network) guidance 3. To investigate whether the implementation of a new ‘Asthma bundle’ between 2014 and 2015 has had any effect upon standards of care

Method: The target population was children over the age of 2 years, admitted to the RVI ward 6 (short stay ward) with wheeze during November 2014 with a diagnosis of asthma exacerbation or acute/viral induced wheeze. Data was collected through the doctor’s asthma management checklist that was distributed with the asthma bundle and through review of the ward 6 admissions book. Notes were collected from ward clerks, paediatric secretaries and medical records.

Results: Pending

Current Reflections and Learning: This was a complex and long process and it was helpful for me to break it into smaller goals and chunks in order to maintain momentum. The collaboration a wide with range of stakeholders (including respiratory paediatricians, general paediatricians, specialist asthma nurses, matron and nursing staff, GPs) had taken place prior to my engagement with the project, but even so there was a long stage of sharing and amending bundle drafts for all the different pieces of documentation before the pilot could take place. The value of the pilot was that it did enable a number of issues to be picked up and amended such as a lack of clarity about inclusion criteria and about who needed a Peak Flow. Then the final version was implemented for the month of November. Unfortunately incomplete take-up has necessitated a case-by-case review of Ward 6 admissions to extract data from other children who did not receive the bundle and this is drawing out the process of attaining a complete set of results.

During this process I reflected on the strengths and weaknesses of a bundle as a concept. On one level they are very effective and having these different components associated has the potential to maximise good care. However it isn’t feasible or sensible to have a bundle for everything. I feel this was a valuable use of a bundle because it is an example of a complex care pathway where there are a lot of different aspects to remember, particularly around the time of discharge.

My favourite aspect of the bundle was the way that it empowered patients and their families. This is because they received a lot of information at the start of the admission which enabled them to find areas of concern or for clarification and they were better placed to ask staff about these, for example on the ward round. It also enabled a form of prompting of both nursing staff (PEF token) and medical staff (the discharge checklist) and led to a shared ownership of the discharge process. However I think the challenge of the folder was that it contained some information that was not relevant to all the patients and this needed to be removed which it wasn’t always – this sometimes led to confusion and was a point that needs highlighting going forward.

I think the success of the bundle has been variable, largely due to inconsistent use. Thus far our data for those who did receive it is extremely positive, demonstrating a much more comprehensive approach to discharge. However it may be that those who didn’t receive it could have had even worse discharge-planning, since many of the other discharge systems were deconstructed in order to prevent duplication. The reasons for inconsistency include the already overworked respiratory SHO (who was not entirely on-side with the project and probably should have been engaged earlier, and the large number of medical doctors working for occasional shifts on Ward 6 who often did not seem aware of the bundle despite emails and numerous posters. The challenges now are around ensuring more consistent implementation. My personal perspective is that in order to do this we should target the nursing staff who are often responsible for supporting patients with information leaflets and are less subject to turnover than the medical staff.

References: 1. Newcastle Upon Tyne Hospitals Trust website; www.newcastle-hospitals.org.uk/ services/accidentemergency_childrens-emergency-department.aspx 2. British Medical Journal Best Practice Website; http://bestpractice.bmj.com/bestpractice/monograph/1098/basics/epidemiology.html 3.

Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K. Using care bundles to reduce inhospital mortality: quantitative survey. BMJ. 2010;340:c1234.

4. SIGN 141 British guideline on the management of asthma, October 2014; http://www.sign.ac.uk/pdf/SIGN141.pdf