An audit of the British Thoracic Society asthma discharge care bundle in a teaching hospital

Asthma is a chronic airway inflammatory condition that can be diagnosed at any age, which leads to airways hyper-responsiveness (Smith et al, 2015). Patients with asthma usually have the following respiratory symptoms: variable cough in terms of intensity and onset, chest tightness, wheeze, shortness of breath and nocturnal disturbance (Global Initiative for Asthma (GINA), 2021). Asthma continues to kill, although most asthma-related deaths are preventable (GINA, 2021). In England and Wales, there has been a 33% rise in asthma deaths over a decade (Iacobucci, 2019). Consequently, caring for asthma patients costs the NHS around £1 billion a year (Asthma UK, 2021).

The main aims of asthma management are to alleviate symptoms, if not eradicate them, and prevent exacerbations and hospital admissions (GINA, 2021). For a better outcome strategy in asthma patients, a group of health professionals and patient bodies performed a systematic National Review of Asthma Deaths (NRAD), Why Asthma Still Kills, of 195 cases over a year (Royal College of Physicians (RCP), 2014). An earlier enquiry, which investigated 90 adult asthma deaths in two regions of England (British Thoracic Association (BTA), 1982), revealed similar issues as the recent one: failure of health professionals to appreciate the importance of adequate objective assessment and take prompt emergency action. In order to tackle the challenges raised by these two reviews, the British Thoracic Society (BTS) (2016) initiated the Asthma Discharge Care Bundle (ADCB) (Figure 1). The ADCB represents a cohesive unit of five evidence-based practices, where all the elements are expected to be used together to improve standards of care for asthma patients before and after discharge (BTS, 2016). The aim of the ADCB is to replicate the successful implementation of their chronic obstructive pulmonary disease (COPD) and their community-acquired pneumonia care bundles in UK acute hospitals.

Figure 1. British Thoracic Society Asthma Discharge Care Bundle

In a pilot study conducted by the BTS and NHS Improvement (BTS, 2014), the use of a community-acquired pneumonia (CAP) care bundle led to 4.8% reduction in acute hospital mortality within 30 days of admission. The individual asthma interventions of the ADCB are:

• All patients (or family members/carers administering medicines) should have their inhaler technique assessed prior to discharge
• All patients should have their medications assessed. The importance of medication adherence to good asthma control should be reinforced to patients (and/or any family members or carers administering medicines) prior to discharge
• A written asthma action plan for how to manage care should be provided to patients and families/carers
• Triggering and exacerbating factors in the patient's overall environment should be considered
• Follow-up in the community to be arranged within 2 working days, plus specialist care according to specified criteria within 2 weeks.

These five statements were audited in the study described in this article.

Audit aims

• To identify whether each of the ADCB statements has been implemented in adult patients admitted with asthma attacks to an acute NHS hospital
• To identify which health professionals implement each of the bundle statements
• To inform local recommendations for promoting the ADCB implementation policy.

Methodology

Healthcare organisations use clinical audits to measure their current clinical performance against an explicit set of established criteria. Clinical audits are recommended in certain chronic conditions, including asthma, because they represent a systematic and valuable mechanism to review the daily health interventions provided to patients (National Institute for Health and Care Excellence (NICE), 2021). The audit described in this article was a retrospective exercise conducted with all adult patients admitted over 12 consecutive months (between 1 November 2018 and 31 October 2019) to an acute teaching hospital for an asthma exacerbation.

For the purposes of this audit, admission refers to patients who were treated for 4 hours or more following their transfer from the emergency department (ED) to other wards. The audit included patients aged 16 years and over, while patients who were discharged from the ED, rather than transferred to another ward, were excluded. A population of 127 patients was initially considered from the existing electronic National Asthma and COPD Audit Programme database and a sample of 86 patients was manually retrieved for the audit in line with the inclusion criteria.

Two tools were used to collect the data, which were entered into a Microsoft Excel spreadsheet for the audit. The first tool, Adult Asthma Secondary Care Clinical Dataset (RCP, 2018a), was used to identify patients discharged from the local hospital following an acute asthma treatment. The second tool, which is the ADCB (BTS, 2016), was used to explore the implementation of the five statements of the bundle in the hospital. The data analysis was done via the Excel spreadsheet using simple descriptive statistics such as percentages.

Ethical approval was not sought because this audit represented a mandatory national audit for which the local hospital had acquired the relevant information governance approval from the Data Protection Office. Permission was obtained from the trust‘s audit office and the trust's asthma lead was informed about the audit. Moreover, the RCP (2018b) has sought ethical approval from the Health Research Authority and Confidentiality Advisory Group (CAG) to collect patients' identifiable data without the need to obtain patient consent. Patients' confidentiality was maintained throughout the audit.

Results

Table 1 presents the demographics of the patients included in the audit. There were 27 males (31%) and 59 females (69%). The 30s and under and the 51-70 groups (29%) made up the greatest proportion of the cohort, followed by the 31-50 age group (26%), with the 71 and above group representing the least patients (16%). Most patients were non-smokers (48%) followed by current smokers (35%). There were 13 (15%) ex-smokers and two of the patients did not have their smoking status recorded.

Table 2 shows the five asthma bundle statements and compliance with them for patients included in the hospital audited. Statement 1 looks at inhaler technique assessed prior to discharge. Out of the 86 patients included in the audit, 85% had their inhaler technique checked; however, 62% of this numbers were not supplied with any written information to support the verbal instructions provided for inhaler use. Statement 2 focuses on a patient's medication assessment. A majority of patients (94%) had their medication reviewed, but 7% of these did not undergo a review of their doses, and in 10% of cases there was no discussion about the importance of adhering to the medication regimen as prescribed.

Statement 3 centres on a written asthma action plan for the patient. Of the 86 patients included in the audit, 62% were provided with an action plan during their admission, 19% were not and 19% already had a plan. Bundle statement 4 looks at the triggering and exacerbating factors. In total, 74% of the patients in the audit did not have documentation recording any discussion of non-steroidal anti-inflammatory drugs (NSAIDs). In 17% of cases there was no discussion with patients about their occupation being a potential trigger for asthma. Of the total number, 27% of patients were elderly, retired or not able to work due to health reasons, so discussion of occupational exposure as a trigger was not applicable. However, for nearly all patients (98%) there was a documented discussion about smoke exposure in their environment.

Bundle statement 5 focuses on follow-up in the community. In the audit, 78% of patients had been referred to their GPs within 48 hours post-discharge and nearly all patients (98%) were referred to the asthma specialists for review 4 weeks after discharge. Two patients did not have a GP review or a specialist follow-up organised post-discharge because one resided outside the UK and the other did not have a GP at the time of discharge. However, advice was provided to both on the importance of asthma follow-up. In total, 15 patients (17%) had scheduled outpatient appointments with their asthma specialists before their hospital admissions.

Table 3 presents the completion of bundle statements 1, 2 and 4 by different health professionals, namely: respiratory clinical nurse specialists (CNSs), the respiratory medical team (consultants, registrars, senior house officers), and the non-respiratory medical team who usually clerk the patients in the ED. In terms of completion of care against bundle statement 1, inhaler technique was checked and inhaler use guidance provided (95% and 94% respectively) by a respiratory CNS. Regarding statement 2, the medication classes were reviewed for 83% patients, medication doses were reviewed in 88% of cases and medication adherence discussed in 79% cases with the patients—this was mostly by the respiratory CNS. The health professional also liaised with the ward pharmacists regarding medication review, but the pharmacists did not keep records of their interactions with patients. With reference to statement 4, most of the discussions around asthma triggers were held by the respiratory CNS: in 81% of cases they highlighted NSAIDs as potential triggers, in 69% ‘other triggers’ were cited and in 60% ‘smoke exposure at home’ was mentioned. Discussions around occupations led by non-respiratory medical team members during clerking were carried out with 58% of patients.

Discussion

The majority of patients who were included in the audit were female (69%), as shown in Table 1. This reflects the statistics reported by the British Lung Foundation (BLF) (2012), which show that between 2004 and 2012 there were more women with asthma than men in the UK. Compared with men, adult women have increased asthma prevalence, their asthma is likely to be more severe and to be later onset. According to a longitudinal study from Finland, among hospitalised patients the prevalence of asthma among women was much higher than among men (P<0.001) (Pelkonen et al, 2018). Although the mechanism is not clear, it has been shown in animal studies that sex hormones affect airway inflammation. Fuseini and Newcomb (2017) found that ovarian hormones appear to increase while testosterone appears to decrease airway inflammation in asthma.

Pelkonen et al (2018) also reported that patients over 70 years old had the lowest hospital admission rates for asthma, which was similar to the findings in this audit (16%). Another finding in this audit that was similar to that in the Pelkonen et al (2018) study was that almost half the patients were lifetime non-smokers. The other half of patients in both our study and Pelkonen et al (2018) were active smokers or ex-smokers, both groups known to be at risk of developing more severe symptoms and worse asthma-specific quality of life—this has significant repercussions for healthcare resources due to the need for frequent hospital admissions (GINA, 2021).

The results of the audit indicated that the hospital had complied with the BTS bundle. Table 2 shows that compliance with most of the statements was above 50%, except for the discussion of NSAIDs (24%) and with regard to the provision of guidance on inhaler use (38%). With respect to bundle statement 1, inhaler technique was checked in the case of 85% of patients and guidance was provided to only 38% of patients. Auditing this particular statement was challenging because the BTS ADCB (2016) document recommends repetition of inhaler technique discussion, but it is not clear whether the guidance provided should be verbal or written. The audit recorded the intervention as compliant only when a patient leaflet was provided. However, good record-keeping is a vital part of effective communication in nursing and integral to promoting patient safety and continuity of care.

Nursing staff need to be clear about their responsibilities for record-keeping in whatever format records are kept (Royal College of Nursing, 2017). A study by Melani et al (2011) involving 1664 patients reported that one third had been provided with written guidance, another third with verbal information only and the remainder had received a practical demonstration using a placebo inhaler. The study also reported a relationship between poor inhaler technique and emergency admissions (P<0.001), as well as a link between high risk of hospital admissions and high levels of illiteracy (P=0.001). The findings were similar to those reported by Basheti et al (2016), who found that a higher level of education seemed to be the only significant factor that affected participants' asthma control. This indicates, therefore, that bundle statement 1 must be adhered to and a record of patients' inhaler technique and any guidance provided should be documented without fail.

Bundle statement 2, which focuses on medication review before discharge (94%), had the highest adherence rate in this audit (Table 3). However, this contradicts the findings for statement 4, which showed that in the case of 74% of patients there was no discussion about the potential involvement of NSAIDs in triggering or exacerbating asthma (Table 2). Because this medication group can be a trigger for an asthma attack it is important to have a comprehensive discussion about a patient's previous adverse reaction to medications. The low compliance with the NSAIDs statement in this audit could be due to the fact that only explicit discussion about NSAIDs was documented in the patient records. This calls for careful interpretation of the BTS discharge bundle as applied in this hospital because NSAIDs could have been discussed at other points during patient assessment, for example under general asthma triggers or under drug allergies. The current audit outcome supports the findings of Pace-Bardon et al (2017), in that the implementation of the asthma care bundles did not increase the assessment of NSAIDs in their audited acute hospital.

Bundle statement 3 relates to the provision of a written asthma action plan that includes guidance for patients about the self-management of the condition—and this is an integral part of asthma management. A written asthma action plan represents a written summary of all the relevant information patients require to live their lives with a minimal level of symptoms (Asthma UK, 2021). It is important that all health professionals involved in asthma management provide patients with a written action plan (BTS and SIGN, 2019; NICE, 2021). Our audit showed almost 81% of patients had been provided with a written plan, 62% of which were initiated during admission by the respiratory CNS. Research (Kuhn et al, 2015) shows that electronic asthma action plans can reduce asthma exacerbations when they are incorporated into patients' medical records at the point of care.

Bundle statement 4 requires health professionals to provide patients with asthma education to enable them to identify and therefore avoid individual exacerbating factors and/or triggers to prevent asthma attacks, and emergency and hospital admissions, as well to avoid complications related to adverse drug reactions (Asthma UK, 2021). Statement 4 centres on common triggers that include NSAIDs, smoking and occupational risks. In view of the fact that more than one quarter of the patients reviewed were retired or not able to work for health reason, discussion around occupational triggers was not applicable in this audit.

According to Asthma UK (2021), 10% of adult onset asthma is caused by patients' employment. However, in some instances, this type of asthma can be disregarded (GINA, 2021): for example, in a prospective study by Wild et al (2017) involving 441 bakery, hairdressing and pastry cooking apprentices at the end of 2 years of training, all participants had developed higher sensitisation to the raw materials they were exposed to during training, which manifests with the same symptoms as asthma.

In the audit described in this article, it was alarming to find that 35% of patients were current smokers and 15% were ex-smokers. This percentage is concerning because smoking leads to a decline in lung function, leading to remodelling in asthmatic lungs, which is when the lungs of patients who have had extensive asthma attacks become rigid rather than flexible (Inwald et al, 2001). Sims et al (2013) revealed in their national longitudinal study that the national smoking ban in workplaces in England led to a decrease in annual asthma emergency admissions by an estimated 1900. They found that smoke-free legislation was associated with an immediate reduction in emergency admissions for asthma in the adult population, which meant that about 1900 emergency admissions for asthma were prevented in each of the first 3 years following the introduction of legislation.

The findings of this audit have shown that smoke exposure was discussed with almost all patients, which is a strong finding. There was a clear finding that most discussions around asthma exacerbating factors were performed by the non-respiratory medical team during clerking in the ED, with no information about NSAID risk provided by the respiratory medical team. Moreover, regarding discussion about the importance of medication adherence, the non-respiratory medical team performed twice as well as the respiratory medical team (14% versus 7%). It could be argued that this difference could be due to the lack of confidence in taking a history of patients' asthma exacerbating triggers: for example, Holness et al (2007) found that 20% of pulmonologists reported a failure to inquire about patients' past workplace exposure and record this.

Bundle statement 5 focuses on post-discharge review to ensure that patients' symptoms do not deteriorate further, and the asthma BTS and SIGN guideline (2019) recommends that respiratory specialists are involved in any follow-up. In this study, 98% of discharged patients were referred to asthma specialist clinics and for 78% of patients the CNS arranged for GP follow-up reviews to take place within 2 working days of discharge. This is similar to the finding by McCreanor et al (2012) who reported that using the ADCB allowed 93.3% of discharged patients to be referred to specialist clinics for asthma review.

Research shows (Osman et al, 2002) that patients who have been reviewed by a CNS in the hospital before discharge are more likely to have outpatient follow-up for their asthma. However, a randomised controlled trial (RCT) by Nathan et al (2006) involving 154 patients found that follow-up reviews carried out in an outpatient clinic within 2 weeks of an acute asthma discharge by either respiratory CNSs or respiratory doctors had no effect on patients' exacerbation rates. The RCP (2014), however, has suggested that a lack of follow-up within 28 days of discharge could have been a possible cause of asthma-related deaths in 10% of the cases that were reviewed by the RCP. Overall, according to the GINA report (2021), monitoring the recovery of patients by either GPs or asthma specialists, or having both reviews following discharge, will reassure patients and will help prevent readmissions. The report suggested that early studies indicate that follow-up by specialists is associated with fewer subsequent ED visits or hospitalisation.

It is important that health professionals should work together when providing patient care. This audit also looked at which health professionals implemented the ADCB statements, as shown in Table 3. Overall, respiratory CNSs complied with most of the statements. However, a cross-sectional, observational study carried out by Melani et al (2011) in Italy found that guidance on inhaler use was most frequently provided by respiratory physicians (54%) followed by GPs (18%), nurses (15%) and, finally, pharmacists (3%). This variation may be due to the different health service structures and numbers of different health professionals: for example, in Italy the ratio of doctors to the population is higher than the European Union average, while the proportion of nurses is relatively low (Organisation for Economic Cooperation and Development et al, 2017).

Our audit also revealed that only 7% of conversations about the importance of medication adherence was conducted by the respiratory medical team versus 14% by the non-respiratory medical team. A study by Peláez et al (2014) found the contrary, with most respiratory physicians reporting that they were solely responsible for ensuring patient adherence to using asthma inhalers. The physicians in this study acknowledged that their responsibility was to prescribe medication and check the patients' response to treatment. All allied health professionals (respiratory technicians, pharmacists, nurses and asthma educators) involved in the Peláez et al (2014) study viewed medication adherence holistically and thought they needed to ensure that patients were able to take the prescribed inhalers correctly. Allied health professional also acknowledged playing the role of patient advocates and bridging any therapeutic gap between doctors and patients (Peláez et al, 2014).

Conclusion

The audit findings revealed that the BTS asthma bundle statements with which there was greatest compliance centred on the discussion of smoke exposure in patients' homes and the referral of patients to asthma specialists in the hospital studied (statements 4 and 5). The statement with which there was least compliance was the discussion about NSAIDs as a potential asthma trigger (statement 4). Most of the bundle statements were implemented by the respiratory CNSs on the admission wards. The audit results also revealed that non-respiratory doctors were more compliant with most of the asthma care bundle statements than the respiratory doctors, and that they usually discussed these statements when clerking patients in the ED.

Every asthma admission should be considered as an opportunity to implement the BTS ADCB while taking a multidisciplinary approach. There is also a need for ongoing asthma knowledge and skills education for all health professionals involved in asthma management, including appropriate history taking and record-keeping. On discharge, it is important to give written information about inhalers for patients who need it—this information can also be given electronically and, where appropriate, in different languages. In addition, it would be appropriate to incorporate the ADCB into local hospital protocols electronically.

Finally, further research needs to be conducted to focus on the implementation of the ADCB in EDs and short-stay admission wards because the current National Asthma and COPD Audit Programme does not look at the care provided in these care settings. It is important that patients admitted to hospital through the ED receive the same care as recommended in the ADCB guidance as those admitted through other routes. This is important in order to understand the existing care pathway for asthma patients and to ensure that they are properly diagnosed, well supported and managed by the appropriate health professionals following discharge. Multidisciplinary team training is essential for all health professional involved in treating asthma patients and, in particular, tailored training for ED staff is essential. More broadly, hospital education co-ordinators could be involved in the wider implementation of such training across trusts.

KEY POINTS

• It is crucial that health professionals are aware of and competent in using the Asthma Discharge Care Bundle
• Completing the Asthma Discharge Care Bundle should be the responsibility of all relevant health professionals and not the sole responsibility of respiratory clinical nurse specialists
• Good record-keeping is a vital part of effective communication in nursing and integral to promoting safety and continuity of care for asthma patients
• Health professionals should consider every asthma admission as an opportunity to educate patients about their condition

CPD reflective questions

• How often should health professionals discuss inhaler technique with asthma patients?
• What are some of the challenges in assessing asthma patients' adherence to medications?
• What is the importance of written asthma action plans for patients?
• Why is it essential to include occupation as a risk factor when taking history in asthma patients?
• What are the barriers to implementing the Asthma Discharge Care Bundle?