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Asthma overview

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Asthma

About

What is covered

This pathway covers NICE guidance on asthma.
To find other information about asthma, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this pathway

8 June 2015 Minor maintenance update.
2 April 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
13 January 2015 Dyspepsia and gastro-oesophageal reflux disease pathway added to related pathways.
23 April 2014 Minor maintenance update.
15 April 2014 Minor maintenance update.
3 April 2014 Minor maintenance update.
1 April 2014 'Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and Nobreath' (NICE diagnostics guidance 12) added to Diagnosis and monitoring and Difficult or severe asthma.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

This pathway covers NICE guidance on asthma.

What is covered

This pathway covers NICE guidance on asthma.
To find other information about asthma, including evidence from NICE Accredited sources, visit NICE Evidence Search.

Updates

Updates to this pathway

8 June 2015 Minor maintenance update.
2 April 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
13 January 2015 Dyspepsia and gastro-oesophageal reflux disease pathway added to related pathways.
23 April 2014 Minor maintenance update.
15 April 2014 Minor maintenance update.
3 April 2014 Minor maintenance update.
1 April 2014 'Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and Nobreath' (NICE diagnostics guidance 12) added to Diagnosis and monitoring and Difficult or severe asthma.

Quality standards

Quality statements

Diagnosis

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.

Rationale

Making a diagnosis of asthma is a process which is different in adults and children and also varies among adults and among children. Processes for adults and children are described in the BTS/SIGN guidance. It is important the process followed is documented to ensure continuity in the diagnostic process. It is also important that the basis on which the diagnosis of asthma is made is clearly recorded because this process may have implications for the future management of the condition. Following the process should result in an accurate diagnosis and ensure the person receives appropriate treatment.

Quality measure

Structure
Evidence of local arrangements to ensure people with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance, and that the process is documented in their patient notes.
Process
Proportion of people with newly diagnosed asthma whose notes describe the process, as outlined in the BTS/SIGN guidance, by which the diagnosis was made.
Numerator – the number of people in the denominator whose notes describe the process, as outlined in the BTS/SIGN guidance, by which the diagnosis was made.
Denominator – the number of people with newly diagnosed asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed asthma to be diagnosed in accordance with BTS/SIGN guidance.
Healthcare professionals ensure people with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.
Commissioners ensure they commission services for people with newly diagnosed asthma to be diagnosed in accordance with BTS/SIGN guidance.
People with newly diagnosed asthma have a diagnosis made in line with BTS/SIGN guidance.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendations in paragraphs 3.1.1, 3.1.7, 3.4, 3.5.1 and 3.5.4.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

The diagnosis and the process by which the diagnosis is made should be documented in the patient’s notes.
The diagnostic process is outlined in the BTS/SIGN guideline, figure 1 for children and in figure 2 for adults, and consists of:
  • history and clinical examination
  • objective tests if the clinical diagnosis is uncertain and
  • response to treatment given in accordance with the BTS/SIGN treatment steps.
The diagnosis is not a one-time event and may need to be reviewed, particularly in younger children.

Diagnosing occupational asthma

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

Adults with new onset asthma are assessed for occupational causes.

Rationale

Occupational asthma is the only form of asthma that can potentially be cured by removing the person from exposure to the trigger. Healthcare professionals need to be able to recognise symptoms that suggest occupational asthma so that they can ensure appropriate referral and treatment.

Quality measure

Structure
Evidence of local arrangements to ensure adults with new onset asthma are assessed for occupational causes.
Process
Proportion of adults with new onset asthma who are assessed for occupational causes.
Numerator – the number of people in the denominator assessed for occupational causes.
Denominator – the number of adults with new onset asthma.
Outcome
Incidence of occupational asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for adults with new onset asthma to be assessed for occupational causes.
Healthcare professionals assess adults with new onset asthma for occupational causes.
Commissioners ensure they commission services that assess adults with new onset asthma for occupational causes.
Adults who have recently developed asthma are assessed for causes linked to their place of work.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendation in paragraph 12.1 and good practice point in paragraph 12.3.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Adults are defined as 16 years and older.
New onset asthma is defined as asthma developing in adults who have not had a previous diagnosis of asthma or a reappearance of childhood asthma in adults.
The BTS/SIGN guideline lists the 2 questions to be asked when assessing for occupational asthma as:
  • Are you better on days away from work?
  • Are you better on holiday?

Written personalised action plans

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with asthma receive a written personalised action plan.

Rationale

Written personalised action plans, given as part of structured education, can improve outcomes such as self-efficacy, knowledge and confidence for people with asthma, particularly for people with moderate to severe asthma whose condition is managed in secondary care. For people with asthma who have had a recent acute exacerbation resulting in admission to hospital, written personalised action plans may reduce readmission rates.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma receive a written personalised action plan.
Process
a) Proportion of people with asthma who receive a written personalised action plan.
Numerator – the number of people in the denominator receiving a written personalised action plan.
Denominator – the number of people with asthma.
b) Proportion of people treated in hospital for an acute exacerbation of asthma who receive a written personalised action plan before discharge.
Numerator – the number of people in the denominator receiving a written personalised action plan before discharge.
Denominator – the number of people treated in hospital for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to receive a written personalised action plan.
Healthcare professionals ensure they give people with asthma a written personalised action plan.
Commissioners ensure they commission services that give people with asthma a written personalised action plan.
People with asthma receive a written plan with details of how their asthma will be managed.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendations in paragraphs 4.2.2, 4.3.1 and 4.3.2 and good practice points in paragraph 4.2.3.

Data source

Structure
Local data collection.
Process
a) and b) Local data collection.

Definitions

A personalised action plan should be tailored to the person with asthma, enabling people with asthma to recognise when symptoms are worse and setting out actions to be taken when asthma control deteriorates.

Equality and diversity considerations

A personalised action plan should be tailored to the person with asthma. The intent of the statement is for people with asthma to not just receive the information verbally but for it to be recorded. This allows people to refer back to the information at a later date. Other formats, such as braille, pictorial or digital, may be needed for particular groups.
For some people with asthma it may be appropriate for a parent or carer to be involved in the review of the written personalised action plan; particularly for children, older people and those with learning disabilities.

Inhaler technique

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment.

Rationale

People with asthma need to be able to use their inhaler correctly to ensure they receive the correct dose of treatment. There are several types of inhaler and it is important that training and assessment are specific to each inhaler.
Training and assessment need to take place before any new inhaler treatment is started, to ensure that changes to treatment do not fail because of poor technique.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Process
Proportion of people with asthma who are given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Numerator – the number of people in the denominator who have training and assessment in inhaler technique.
Denominator – the number of people with asthma starting a new inhaler treatment.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to be given specific training and assessment in inhaler technique before starting any new inhaler treatment.
Healthcare professionals ensure people with asthma receive specific training and assessment in inhaler technique before starting any new inhaler treatment.
Commissioners ensure they commission services that give people with asthma specific training and assessment in inhaler technique before they start any new inhaler treatment.
People with asthma are given training in using their inhaler before they start any new inhaler treatment.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendation in paragraph 7.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

During an assessment of inhaler technique the person with asthma should demonstrate that they can use the inhaler as specified in the manufacturer’s guidance.

Review

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with asthma receive a structured review at least annually.

Rationale

A structured review can improve clinical outcomes for people with asthma. Benefits associated with structured review may include reduced absence from school or work, reduced exacerbation rate, improved symptom control and reduced attendance in accident and emergency departments.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma receive a structured review at least annually.
Process
Proportion of people with asthma who receive a structured review at least annually.
Numerator – the number of people in the denominator who had a structured review within 12 months of the last review or diagnosis.
Denominator – the number of people with asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma to receive a structured review at least annually.
Healthcare professionals ensure people with asthma receive a structured review at least annually.
Commissioners ensure they commission services that give people with asthma a structured review at least annually.
People with asthma have a review of their asthma and its management at least once a year.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendations in paragraphs 3.6.3, 3.6.4 and 13.3.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Components of a structured review
The components of a structured review are set out in the BTS/SIGN guideline paragraphs 3.6.3 and 3.6.4. The review will vary for adults and children.
Components of a structured review for children include:
  • assessment of symptomatic asthma control using a recognised tool
  • review of exacerbations, oral corticosteroid use and time off school or nursery as a result of asthma since last assessment
  • checking inhaler technique
  • assessing adherence (which can be done by reviewing prescription refill frequency)
  • adjustment of treatment (consider stepping up if poor control or stepping down if good control since the last annual review)
  • possession and review of personalised action plan
  • exposure to tobacco smoke
  • measurement of growth centile (height and weight)
  • assessment of comorbidities
  • review of diagnosis.
Components of a structured review for adults include:
  • assessment of symptomatic asthma control using a recognised tool
  • measurement of lung function, assessed by spirometry or by peak expiratory flow
  • review of exacerbations, oral corticosteroid use and time off work or study since last assessment
  • checking inhaler technique
  • assessing adherence (which can be done by reviewing prescription refill frequency)
  • adjustment of treatment (consider stepping up if poor control or stepping down if good control since the last annual review)
  • bronchodilator reliance (which can be assessed by reviewing prescription refill frequency)
  • possession and review of personalised action plan
  • smoking status
  • assessment of comorbidities
  • review of diagnosis.
Assessment of asthma control
An assessment of asthma control should use a recognised tool (see BTS/SIGN guideline, table 8). The tool used should be appropriate for the age of the person with asthma. The available tools include:
  • Royal College of Physicians (RCP) 3 questions
  • asthma control questionnaire
  • asthma control test or children’s asthma control test
  • mini asthma quality of life questionnaire or paediatric asthma quality of life questionnaire.
These tools are usefully supplemented by 1 or more tests of airway function, which include:
  • spirometry
  • peak expiratory flow
  • airway responsiveness
  • exhaled nitric oxide
  • eosinophil differential count in induced sputum.

Assessing asthma control

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with asthma who present with respiratory symptoms receive an assessment of their asthma control.

Rationale

For people who present with respiratory symptoms between annual reviews, it is important to assess asthma control using a recognised tool to identify those who need treatment. In some cases this may prevent admission to hospital for deteriorating symptoms.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma presenting with respiratory symptoms receive an assessment of their asthma control.
Process
Proportion of people with asthma presenting with respiratory symptoms who receive an assessment of their asthma control.
Numerator – the number of people in the denominator receiving an assessment of their asthma control.
Denominator – the number of people with asthma who present with respiratory symptoms.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma who present with respiratory symptoms to receive an assessment of their asthma control.
Healthcare professionals assess asthma control in people with asthma who present with respiratory symptoms.
Commissioners ensure they commission services that assess asthma control in people with asthma who present with respiratory symptoms.
People with asthma who have symptoms have an assessment of how well their asthma is controlled.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, good practice points in paragraphs 3.6.1 and 3.6.2.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Respiratory symptoms include cough, wheezing, breathlessness and chest tightness.
Assessment of asthma control
An assessment of asthma control should use a recognised tool (see BTS/SIGN guideline, table 8). The tool used should be appropriate for the age of the person with asthma. The available tools include:
  • Royal College of Physicians (RCP) 3 questions
  • asthma control questionnaire
  • asthma control test or children’s asthma control test
  • mini asthma quality of life questionnaire or paediatric asthma quality of life questionnaire.
These tools are usefully supplemented by 1 or more tests of airway function, which include:
  • spirometry
  • peak expiratory flow
  • airway responsiveness
  • exhaled nitric oxide
  • eosinophil differential count in induced sputum.

Assessing severity

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation.

Rationale

Severity of an exacerbation should be objectively measured as soon as a person presents with respiratory symptoms. Delays in measurement can result in symptoms deteriorating further. An accurate measurement can determine the level of severity of the attack and ensure appropriate treatment is started promptly.

Quality measure

Structure
Evidence of local arrangements to ensure people with asthma presenting with an exacerbation of their respiratory symptoms receive an objective measurement of severity at the time of presentation.
Process
Proportion of people with asthma presenting with an exacerbation of their respiratory symptoms who receive an objective measurement of severity at the time of presentation.
Numerator – the number of people in the denominator receiving an objective measurement of severity at the time of presentation.
Denominator – the number of people with asthma presenting with an exacerbation of their respiratory symptoms.

What the quality statement means for each audience

Service providers ensure systems are in place for people with asthma who present with an exacerbation of their respiratory symptoms to receive an objective measurement of severity at the time of presentation.
Healthcare professionals ensure people presenting with an acute exacerbation of asthma receive an objective measurement of severity at the time of presentation.
Commissioners ensure they commission services that give people with asthma who present with an exacerbation of their respiratory symptoms an objective measurement of severity at the time of presentation.
People with asthma who go to see a healthcare professional because their symptoms have worsened have their symptoms measured at the time of the appointment.

Source guidance

Consensus based on annex 3–7 and guidance in paragraph 8.2.3 in BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Respiratory symptoms include cough, wheezing, breathlessness and chest tightness.
Objective measurement of severity
The clinical signs to assess when determining the severity of an exacerbation differ for adults, children aged 2–5 years and children aged older than 5 years. The measurements are outlined below and in the BTS/SIGN guideline: table 12 or annex 3 for adults and table 14 or annex 5, 6 or 7 for children older than 2 years.
Children aged 2–5 years
Moderate asthma
Severe asthma
Life-threatening asthma
SpO2 ≥92%
Able to talk
Heart rate ≤140/minute
Respiratory rate ≤40/minute
SpO2 <92%
Too breathless to talk
Heart rate >140/minute
Respiratory rate >40/minute
Use of accessory neck muscles
SpO2 <92% plus any of:
  • silent chest
  • poor respiratory effort
  • agitation
  • altered consciousness
  • cyanosis
Children older than 5 years
Moderate asthma
Severe asthma
Life-threatening asthma
SpO2 ≥92%
PEF ≥50% best or predicted
Able to talk
Heart rate ≤125/minute
Respiratory rate ≤30/minute
SpO2 <92%
PEF 33–50% best or predicted
Too breathless to talk
Heart rate >125/minute
Respiratory rate >30/minute
Use of accessory neck muscles
SpO2 <92% plus any of:
  • PEF <33% best or predicted
  • silent chest
  • poor respiratory effort
  • agitation
  • altered consciousness
  • cyanosis
Adults
Measure peak expiratory flow (PEF) and arterial saturation
PEF >50–75% best or predicted
PEF 33–50% best or predicted
PEF <33% best or predicted
Moderate asthma
Acute severe asthma
Life-threatening asthma
SpO2 ≥92%
PEF >50–75% best or predicted
No features of acute severe asthma
Features of severe asthma
  • PEF<50% best or predicted
  • Respiration ≥25/minute
  • SpO2 ≥92%
  • Pulse ≥110 breaths/minute
  • Cannot complete sentence in 1 breath
  • SpO2 <92%
  • Silent chest, cyanosis, poor respiratory effort
  • Arrhythmia, hypotension
  • Exhaustion, altered consciousness

Treatment for acute asthma

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.

Rationale

Steroids are part of a range of treatment that can be given to people aged 5 years or older presenting with a severe or life-threatening exacerbation of asthma.
The use of steroids soon after presentation may contribute to reducing the need for hospital admission, preventing relapse in symptoms, reducing mortality and the need for β2 agonist therapy.

Quality measure

Structure
Evidence of local arrangements to ensure people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.
Process
Proportion of people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma who receive oral or intravenous steroids within 1 hour of presentation.
Numerator – the number of people in the denominator receiving oral or intravenous steroids within 1 hour of presentation.
Denominator – the number of people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma to receive oral or intravenous steroids within 1 hour of presentation.
Healthcare professionals ensure people aged 5 years or older presenting to them with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation.
Commissioners ensure they commission services that give oral or intravenous steroids to people aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma within 1 hour of presentation.
People aged 5 years or older who see a healthcare professional with severe or life-threatening asthma are given oral or intravenous steroids within 1 hour.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendations in paragraphs 8.3.3, 8.8.4 and 11.2 and guidance in annex 3–7.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

The BTS/SIGN guideline defines severe and life-threatening asthma in table 12 for adults and table 14 for children.

Specialist review

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.

Rationale

A structured review of clinical management and the written personalised action plan ensure people admitted to hospital receive appropriate treatment and in some cases may reduce readmission rates.

Quality measure

Structure
Evidence of local arrangements to ensure people admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge.
Process
Proportion of people admitted to hospital with an acute exacerbation of asthma who receive a structured review by a member of a specialist respiratory team before discharge.
Numerator – the number of people in the denominator receiving a structured review by a member of a specialist respiratory team.
Denominator – the number of people discharged from hospital after admission for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people admitted to hospital with an acute exacerbation of asthma to be reviewed by a member of a specialist respiratory team before discharge.
Healthcare professionals ensure people admitted to hospital with an acute exacerbation of asthma are reviewed by a member of a specialist respiratory team before discharge.
Commissioners ensure they commission services which give people admitted to hospital with an acute exacerbation of asthma a review by a member of a specialist respiratory team before discharge.
People admitted to hospital with a sudden worsening of asthma have a review by a member of a specialist team before discharge.

Source guidance

Consensus based on guidance from paragraph 4.3.2 in BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Structured review
A structured review should include:
  • an assessment of events leading up to the attack (including exposure to triggers, adherence and inhaler technique)
  • review of the written personalised action plan
  • review of regular treatment including considering whether this needs to be changed.
Specialist respiratory team
Specialist respiratory team is defined as a team in which the clinical lead is a respiratory consultant (adult or paediatric) or a specialist with an interest in respiratory disease (adult or paediatric) or a trained specialist nurse with expertise in managing asthma.

Equality and diversity considerations

A personalised action plan should be tailored to the person with asthma. The intent of the statement is for people with asthma to not just receive the information verbally but for it to be recorded. This allows people to refer back to the information later. Other formats, such as braille, pictorial or digital, may be needed for particular groups.
For some people with asthma it may be appropriate for a parent or carer to be involved in the review of the written personalised action plan, particularly for children, older people and those with learning disabilities.

Follow-up in primary care

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment.

Rationale

For people treated for an exacerbation of asthma in hospital (both in accident and emergency departments and as inpatients) or through out-of-hours services, follow-up appointments are important to explore the possible reasons for the exacerbation and the actions needed to reduce the risk of further acute episodes.

Quality measure

Structure
a) Evidence of local arrangements to ensure people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2 working days of treatment.
b) Evidence of local arrangements to ensure effective communication between secondary care centres (such as hospitals and out-of-hours services) and primary care.
Process
Proportion of people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma who are followed up by their own GP practice within 2 working days of treatment.
Numerator – the number of people in the denominator followed up by their own GP practice within 2 working days of treatment.
Denominator – the number of people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma to be followed up by their own GP practice within 2 working days of treatment.
Healthcare professionals follow up all people in their own practice who received treatment for an acute exacerbation of asthma in hospital or through out-of-hours services within 2 working days of treatment.
Commissioners ensure they commission services that specify effective communication between secondary care centres (such as hospitals and out-of-hours services) and primary care so that people who received treatment for an acute exacerbation of asthma in hospital or through out-of-hours services are followed up by their own GP practice within 2 working days of treatment.
People who received treatment in hospital or through out-of-hours services for a sudden worsening of their asthma see a healthcare professional in their own GP practice within 2 working days of treatment.

Source guidance

Consensus based on annex 3 and guidance from paragraphs 8.6.3, 8.9.5 and 8.11.4 in BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141.

Data source

Structure
a) and b) Local data collection.
Process
Local data collection.

Definitions

People who received treatment in hospital include both people treated in accident and emergency departments and those treated as inpatients
People admitted with an acute exacerbation should be followed up within 2 days of discharge; people not admitted but treated for an acute exacerbation should be followed up within 2 days of treatment.

Difficult asthma

This quality statement is taken from the asthma quality standard. The quality standard defines clinical best practice in asthma care and should be read in full.

Quality statement

People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.

Rationale

People with difficult asthma need specialist assessment to accurately diagnose their asthma, exclude alternative causes of persistent symptoms, manage comorbidities, confirm adherence to therapy and ensure they are receiving the most appropriate treatment.

Quality measure

Structure
Evidence of local arrangements to ensure people with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service.
Process
Proportion of people with difficult asthma who receive an assessment by a multidisciplinary difficult asthma service.
Numerator – the number of people in the denominator receiving an assessment by a multidisciplinary difficult asthma service.
Denominator – the number of people with difficult asthma.

What the quality statement means for each audience

Service providers ensure systems are in place for people with difficult asthma to be offered an assessment by a multidisciplinary difficult asthma service.
Healthcare professionals offer people with difficult asthma an assessment by a multidisciplinary difficult asthma service.
Commissioners ensure they commission services that offer people with difficult asthma an assessment by a multidisciplinary difficult asthma service.
People with asthma that is difficult to control are offered an assessment by a team that specialises in managing ‘difficult asthma’.

Source guidance

BTS/SIGN (2014) British guideline on the management of asthma SIGN clinical guideline 141, recommendations in paragraph 9.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

Difficult asthma for adults
The definition of difficult asthma in adults was agreed by consensus and aligns with the interim specification for Respiratory Severe asthma.
Difficult asthma in adults is defined as asthma with symptoms despite treatment at steps 4 or 5 of the BTS/SIGN guideline plus 1 of the following:
  • an event of acute severe asthma which is life threatening, requiring invasive ventilation within the last 10 years
  • requirement for maintenance oral steroids for at least 6 months at a dose equal to or above 7.5 mg prednisolone per day or a daily dose equivalent of this calculated over 12 months
  • 2 hospitalisations within the last 12 months in patients taking and adherent to high dose inhaled steroids (greater than or equal to 1000 micrograms of beclometasone or equivalent)
  • fixed airflow obstruction, with a post bronchodilator FEV1 less than 70% of predicted normal.
Difficult asthma for children
The definition of difficult asthma in children was agreed by consensus and aligns with the interim service specification for Paediatric Medicine: Respiratory.
Difficult asthma in children is defined as stage 3 or 4 but still symptomatic, especially if high dose inhaled corticosteroids have been used, and all stage 5 (aged 5 years and older) or stage 4 (younger than 5 years) as per the BTS/SIGN guideline.
Assessment
The BTS/SIGN guideline states a systematic evaluation should include:
  • confirmation of the diagnosis of asthma and
  • identification of the mechanism of persisting symptoms and
  • assessment of adherence with therapy.
Difficult asthma service for adults
The service requirements to be met by a difficult asthma service for adults are set out in the interim specification for Respiratory Severe asthma.
Difficult asthma service for children
The service requirements to be met by a difficult asthma service for children are set out in the interim service specification for Paediatric Medicine: Respiratory.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Paths in this pathway

Pathway created: March 2014 Last updated: June 2015

© NICE 2016

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