A toolkit to identify and review patients at risk of poor outcomes: reducing exacerbations, admissions and improving symptom control
Toolkit includes five EMIS Web search reports and three protocol alerts. FREE to download.
This toolkit was developed with the help of a grant from Thermo Fisher Scientific.
A person’s asthma symptoms may be triggered or exacerbated by a wide variety of causes: viral infections, allergens (both aero-allergens such as house dust mites, pollens and animal hair; or oral allergens such as eggs or nuts), environmental factors such as tobacco smoke and air pollutants, climatic variation, exercise, stress and some medicines. For many people, particularly those whose underlying asthma is poorly controlled, these triggers can cause asthma attacks which at their worst can be life threatening or, more rarely, fatal.
To ensure that people with asthma are free from symptoms and attacks and are able to lead a normal, active life, NRAD recommends that each patient should have their asthma triggers identified and documented in their medical records and action plans (1). To support the identification of these triggers, NICE recommends that skin prick tests to aeroallergens or specific IgE tests should be undertaken after a formal diagnosis of asthma has been made (2). The importance of allergic sensitisation as a predictor for the development of persistent asthma is also highlighted by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) (3), as well as the Global Initiative for Asthma (GINA) (4).
Most importantly, triggers should be specified as part of a person’s asthma action or management plan and incorporated into their self-management education.
As a result, it is recommended that all people with asthma should be provided with written guidance in the form of a personal asthma action/management plan that details their own triggers and current treatment, and specifies how to prevent relapse and when and how to seek help in an emergency. The presence of a plan and the factors that trigger or exacerbate asthma should also be recorded in the patient’s medical record. People at high risk should have their plans reviewed and updated at each review (1).
The benefits of written action plans – reduced healthcare utilisation, improved quality of life and symptoms (5), and reduced mortality (6) – are supported by strong evidence and their use is recommended across international clinical guidelines. In the UK, the BTS / SIGN Asthma Guidelines (3), NICE Asthma Guidelines (2) and Quality Standards (7) and the Quality and Outcomes Framework (QOF) (8) all reinforce the importance of action plans.
To support practitioners in the identification of patients who may be at risk of poor outcomes, we have developed the Managing Allergic Triggers in Asthma Toolkit. The toolkit comprises a series of discrete EMIS Web search reports and protocol alerts which focus on the following to highlight and prioritise vulnerable patients.
Search reports list patients who are already displaying markers of poor disease control – for example, high use of short-acting bronchodilators (SABAs), recent exacerbations and/or hospital admissions, and courses of oral prednisolone in the last 12 months.
Of these at-risk patients, reports will identify those patients who do not have a personalised asthma action plan, documented triggers, history of a skin prick test or specific IgE test and/or displaying signs of atopy. Where appropriate, the reports will also indicate if patients are currently receiving an inhaled corticosteroid and the last date of issue.
Changing seasons can lead to an increase in asthma for a range of reasons. Reduced temperatures and an increase in respiratory infections contribute to December and January being the deadliest months of the year for people with asthma. Data from 2006 and 2015 reveal that more people die of asthma attacks in January compared to any other month of the year, with an average of 154 deaths. This is closely followed by December with an average of 141 deaths (11).
Conversely, in spring and summer, airborne allergens such as pollens and spores can be a particular problem, along with a tendency towards poorer air quality. Patients who are sensitised to aero-allergens are at particular risk of exacerbations.
A ‘seasonal’ search has been developed – highlighting patients with poor control who haven’t been issued an inhaled corticosteroid in the last four months– which should be run in advance of seasonal peaks.
A specific search has been created to list all asthma patients diagnosed in the last 12 months highlighting those who do not yet have a record of a personalised asthma action plan, documented triggers, history of a skin prick test or specific IgE test.
Every September in the UK, there’s a spike in asthma attacks in children as they return to school (9) – the total number of emergency hospital admissions for asthma typically jumps between August and September from around 3,500 to more than 6,000 (10).
There are a few possible reasons why children are at higher risk after returning to school: respiratory infections, dust mite and mould allergies, air pollution, allergic reactions to cleaning products (many schools are deep-cleaned in the summer holidays) and the stress of term starting. It’s also possible that childrens’ preventer inhaler routines get disrupted over the summer holidays.
A search has been created for practices to run in the summer holidays as a prompt to review children and ensure their asthma is well controlled prior to their return to school. The search creates a list of school-age asthma patients who are displaying markers of poor disease control and highlights when the child was last issued with an inhaled corticosteroid, the date of their last review and whether they have a personalised asthma action plan, documented triggers, history of a skin prick test or specific IgE test.
Practical search reports and protocol alerts to identify asthma patients displaying signs of poor disease control and at risk of poor outcomes.
Patient identification criteria consistent with national guidelines and best practice recommendations.
Seasonal searches tailored to reducing the risk of exacerbations for asthma patients susceptible to seasonal triggers.
Developed in partnership between the Midlands Practice Pharmacy Network and Prescribing Decision Support Ltd at Keele University.
Available to download and free to use. Compatible with EMIS Web.
With special thanks to the following who provided clinical and technical expertise to support the toolkit’s development: Terri Chandler – Allergy Nurse Specialist, Colchester: Jaz Dhillon - Pharmacist, Walsall; Hemal Gohel – Pharmacist, Birmingham; Jo Hamilton – Lead Respiratory Nurse, Dudley; Jas Johal – Pharmacist, Dudley; Mei Kee Kok – Pharmacist, Shropshire; Viv Marsh – Specialist Asthma Nurse, Dudley; Bharat Patel – Pharmacist, Walsall; Simon Wathall – Health Informatics Specialist, Keele University.
1. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. 2014. 2. NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. 2017 (updated 2021). 3. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158. British Guideline on the Management of Asthma. 2019 4. Global Initiative for Asthma. GINA Report, Global Strategy for Asthma Management and Prevention. 2021 5. Gibson PG, Powell H, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003; CD001117. 6. Abramson MJ, Bailey MJ, Couper FJ, et al. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2001; 163: 12–18. 7. NICE. Asthma Quality Standard. QS25. 2013 (updated 2018). 8. NHS England, British Medical Association. Quality and Outcomes Framework guidance for 2021/22. 2021. 9. Asthma UK. Avoid a back to school asthma attack. 2021. 10. NHS England. NHS warning to parents as ‘asthma season’ hits. 2019. 11. Asthma UK. Peak in asthma deaths sparks winter survival guide. Figures sourced from the Office for National Statistics (England and Wales), the Northern Ireland Statistics and Research Agency and the National Records of Scotland. Accessed 2022.
Prescribing Decision Support, Centre for Medicines Optimisation, The Hornbeam, Keele University, Keele, Staffordshire, ST5 5BG.
For any enquiries to Thermo Fisher Scientific. firstname.lastname@example.org
Developed in partnership between the Midlands Practice Pharmacy Network and Prescribing Decision Support Ltd at the Centre for Medicines Optimisation, Keele University. Both parties reserve the right to update and change the Managing Allergic Triggers in Asthma Toolkit at any time in order to address changes in clinical guidance and best practice, improve functionality and reflect changing user and business needs. Both parties also reserve the right to withdraw the Toolkit if and when its content is out of date and no longer consistent with clinical guidance.
© 2022 PDS Ltd