New approach needed to fill gaps in paediatric asthma post discharge care

Respiratory specialists are calling for a standardised approach to the management of post discharge care for children admitted to hospital with acute asthma attack after a NSW study uncovered significant variability in the care offered to young patients.

Gaps and substantial variations in care were found in areas such as adherence with asthma clinical practice guidelines and use of asthma action plans (AAPs) – both within and across different health districts of New South Wales and between ED and paediatric wards within hospitals.

Speaking to the limbic, lead investigator Dr Nusrat Homaira, respiratory physician and epidemiologist at the Sydney Children’s hospital in Randwick, described the situation as ‘a mess’, adding that the different documents and follow up care pathways were confusing for parents and children alike.

“Asthma is a controllable disease and in a country like Australia kids shouldn’t be dying from their asthma,” she said. pointing to figures from the Child Health Death Report, which showed that in NSW there were 20 deaths from asthma between 2013-14.

It was that devastating figure that prompted Dr Homaira and her team to examine the state of post discharge asthma care in NSW.

“In the Child Health Death report it was identified that more than 50% of those children had preventable risk factors, like psychosocial or environmental risk factors, [which] could have been addressed if they were under surveillance and we knew what was going on with them. They’re clearly falling through the cracks and we wanted to know why this was happening.”

Cornerstones of care

The survey covered 37 hospitals across the state and was completed by 502 nursing and medical staff. It captured information about the services and resources used to deliver what Dr Homaira said was the cornerstone of asthma care: the use of clinical, evidence-based guidelines, the use of personalised asthma action plans (AAPs); provision of parent or carer education and proactive follow up to ensure that children receive regular follow up from their primary care provider every three to four months.

A key finding, explains Dr Homaira, is that while nearly all respondents reported using clinical guidelines in management of asthma exacerbations, several different clinical practice guidelines were used within the same hospital and between different hospitals within the same LHDs.

And though approximately 89% of respondents reported that AAPs were provided to parents when their child was discharged from hospital it was patients in paediatric wards who were more likely to receive an AAP upon their discharge from the hospital (98.1%; 95% CI=95.2–99.5) than those in EDs (80.9%; 95% CI=75.7–85.5). What’s more, a variety of AAPs were reported by respondents to have been provided to parents/carers upon their child’s hospital discharge.

Such discrepancies not only lead to variation of care but also create confusion about the best treatment option for patients, said Dr Homaira.

It’s an issue that many hospital staff recognised as a problem too, with some 24% (64/282) of respondents identifying the use of different AAPs or asthma management guidelines as being a ‘major issue’ in childhood asthma care as it might cause confusion to parents or carers.

Other gaps included post-hospitalisation follow-up. While follow-up within 2–3 days was recommended by 70% of respondents, only 8% reported that hospitals had a system in place to ensure follow-up compliance.

Formal asthma education sessions (27% respondents) were seldom provided to parents/carers during hospital stays, especially in EDs (14% respondents). Less than 50% of the respondents were aware of any asthma community services for children and only 4% reported that schools/childcare services were notified about the child’s hospital admission for an asthma flare up.

New model of care

While the findings have highlighted the desperate need for a standardised approach to asthma care, Dr Homaira and colleagues have already begun work incorporating the survey findings into a new model of coordination care at the Sydney Children’s Hospital. The model has so far reduced asthma presentation readmissions by 56%.

“We initiated a care coordination component to post-discharge care whereby a care coordinator makes sure the child has a standard asthma pack when they’re discharged from the hospital. It has an asthma plan, an asthma resource book, a letter for their GP and for their school. The care coordination also links up to the GP so we can see when the child goes for their follow up visit.”

The care coordinator prompts parents and carers to maintain regular GP visits with text message reminders and sets up virtual home visits to make sure that patients and parents have an action plan, that medications are properly used and that there are no home environment tiggers.

The model, which Dr Homaira said was not labour or resource intensive, has now become standard care at the hospital.

“In most hospitals there are asthma CNCs [clinical nurse consultants] and asthma nurses so we can leverage the existing workforce and platforms already in place. It’s really about bringing all the relevant stakeholders involved in the pathway of asthma management under the same umbrella and connecting them.”

Funding from Asthma Australia has now meant the program will be initiated at other hospitals with Liverpool Hospital in Sydney’s South West next to trial the care coordination model.

The study was published in the Journal of Asthma and Allergy.

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