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Personalised care in asthma

A primary care nurse's quick guide to…

Personalised care in asthma

Key learning points:

1.    Personalised care planning, in the form of an individual written action plan, is a key feature of best practice for asthma management in primary care

2.    Personalised asthma action plans may improve patients'knowledge, confidence, symptom control, and reduce hospital admission and readmission

3.    Despite these benefits, personalised asthma action plans are under-utilised; primary care nurses can aid effective implementation

Asthma is the most common long-term condition in the UK, affecting up to 5.4 million people. Many asthma patients are managed in primary care - therefore nurses in the setting have a role in ensuring best practice, a key feature of which is personalised care.1,2,3,4

What is personalised care in asthma?

Personalised care planning involvesa conversation- or series of conversations - between a patient and health professionals, to agree how to manage the patient's condition. The King's Fund stresses that this is a continuous process, not a one-off event.5,6

It has been recommended in asthma management for a quarter of a century, and the National Institute for Health and Care Excellence (NICE) states that healthcare professionals should ensure that every asthma patient has a written, personalised plan.1,7,8

The gold standard for asthma management, the guideline from the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN), says that asthma is best managed in primary care by at least annual clinical review, carried out by a nurse or doctor with appropriate training. The written personalised asthma action planshould be monitored and recorded as part of this.3

Why are written asthma action plans important?

NICE says that personalised asthma plans, given as part of structured patient education, can improve outcomes such as knowledge and confidence for patients.

Asthma UK says that patients who use them are less likely to have symptoms and time off work or school1,9 and are four times less likely to be admitted to hospital for the condition. And NICE says the plans may also reduce readmission rates for people who have recently been admitted to hospital for an exacerbation (asthma attack).1,9,10

A Cochrane systematic review found that patient involvement in personalised care planning probably led to small improvements in control of asthma, reduced symptoms of depression and improved people's confidence and skills to manage their health. However, it found no effect on quality of life.5

What does an action plan contain?

The BTS SIGN guideline states that personalised asthma action plans should be based on symptoms and/or peak flow, with the former more suitable for children.3

A systematic review identified the features of action plans associated with beneficial outcomes. These are summarised in a table in the BTS SIGN guideline, which particularly highlights two features:

·      Specific advice about recognising loss of asthma control.

·      Two or three action points if asthma deteriorates.3,11

Asthma UK says the plans should help patients to:

•   Monitor their asthma.

•   Understand when and how to take their medicine to keep their asthma well managed.

•   Control their asthma after loss of adherence.

•   Identify signs that their asthma is getting worse, so they can get help quickly and reduce the risk of an exacerbation.

•   Understand what to do if they have an exacerbation.

•   Let their friends and family know what to do in an emergency.

•   Check when their next review is due.

•   Find their GP or asthma nurse's contact number.9

The charity provides action plan templates, including one for children aged six to 11. Sections to fill in include the patient's:

•   Symptom triggers.

•   Normal management plan.

•   The signs of worsening control and how to treat it.

•   The signs of an exacerbation and what to do in an emergency.

•   Next asthma review date.

•   Health professional contact telephone numbers.12,13

Notes for primary care nursing

Despite the benefits, researchers have described personalised asthma action plans as under-implemented, under-reviewed, undervalued and under-supported. In a national review of 195 deaths from asthma, only 23% of the patients had action plans. Asthma UK has found that 74% of people seeking help for their asthma - either from their GP or hospital - did not have a written asthma action plan.3,7,9,10,14

Primary care health professionals therefore have an important role in ensuring that patients get the most out of personalised asthma action plans.

Asthma UK advises patients to:

•   Keep their plan somewhere easily accessible.

•   Carry a physical copy and also take a photo of it on their phone.

•   Show their plan to those they are close to or travelling with.

•   Take their plan to every medical appointment, including hospital admissions.

•   Set a calendar reminder to read it once a month.9

The Cochrane review found that personalised care planning worked best when it included preparation, record-sharing, care co-ordination, review, intensive support from health professionals, and was integrated into routine care.5

Training to support practice nurses in implementing personalised asthma action plans has been found to increase quality of life, although not asthma control or medicine use.15

School nurses will have a particular role to play in familiarising themselves with students' personalised asthma action plans and making sure teachers and other school staff also do so. Asthma UK recommends that parents of new students book an appointment with the school nurse.16

The future of practice

NICE is developing a guideline on asthma diagnosis and monitoring. It includes more emphasis on objective testing, such as lung function tests, to support asthma diagnosis, particularly in children. Therefore we may see an increasing expectation that personalised asthma action plans will be based on peak flow as well as symptoms, particularly in children.17,18

Resources

Asthma UK templates for personalised asthma action plans:

•   for adults and children over 12 https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf

•   for children aged six to 11 https://www.asthma.org.uk/globalassets/health-advice/child-asthma-action-plan.pdf

References

1.    Nice. QS25. Asthma. February 2013. https://www.nice.org.uk/guidance/qs25

2.    Asthma UK. Asthma Facts and Statistics. https://www.asthma.org.uk/about/media/facts-and-statistics/(accessed 13 June 2016)

3.    British Thoracic Society - Scottish Intercollegiate Guidelines Network. Sign 141. British guideline on the management of asthma. Healthcare Improvement Scotland. 2003, revised 2014. http://www.sign.ac.uk/pdf/SIGN141.pdf

4.    Managing asthma in primary care: putting new guideline recommendations into context. Mayo Clin Proc. 2009 Aug; 84(8): 707-717. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719524/(accessed 13 June 2016)

1.     Coulter A, Entwistle VA, Eccles A, Ryan S, Shepperd S, Perera R. Personalised care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews 2015.Issue 3 Art. No.: CD010523.http://www.cochrane.org/CD010523/COMMUN_effects-of-personalised-care-planning-for-people-with-long-term-conditions

2.    Coulter A, Roberts S, Dixon A. Delivering better services for people with long-term

3.    conditions. The King's Fund. October 2013. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/delivering-better-services-for-people-with-long-term-conditions.pdf

4.    Ring N et al.The 'vicious cycle' of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals' views. BMC Family Practice. 2015 16:145. http://bmcfampract.biomedcentral.com/articles/10.1186/s12875-015-0352-4

5.    Woolcock A, Rubinfeld A, Seale J, Landau L, Antic R, Mitchell C, et al. Asthma management plan. Med J Australia. 1989;151:650-3.

6.    Asthma UK. Your asthma action plan. https://www.asthma.org.uk/advice/manage-your-asthma/action-plan/(accessed 14 June 2016)

7.     Adams et al; Factors associated with hospital admissions and repeat emergency department visits for adults with asthma; Thorax2000;55:566-573

8.    Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax2004;59(2):94-9.

9.     Asthma UK. Adult asthma action plan. https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf(accessed 14 June 2016)

10.  Asthma UK. Child asthma action plan. https://www.asthma.org.uk/globalassets/health-advice/child-asthma-action-plan.pdf(accessed 14 June 2016)

11.Levy M et al. Why asthma still kills - The National Review of Asthma Deaths. Royal College of Physicians. May 2014. https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills

12.Cleland JA, et al. An exploratory, pragmatic, cluster randomised trial of practice nurse training in the use of asthma action plans. Prim Care Resp J2007; 16(5): 311-318. https://www.researchgate.net/profile/David_Price25/publication/5910052_An_exploratory_pragmatic_cluster_randomised_trial_of_practice_nurse_training_in_the_use_of_asthma_action_plans/links/00b49527fd2ee66116000000.pdf

13.Asthma UK. Asthma at school and nursery. https://www.asthma.org.uk/advice/child/life/school(accessed 14 June 2016)

14.Nice. GID-CGWAVE0743. NICE guideline: Asthma management Final scope. Draft. https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0743

15.McArthur R, Small I. A Quick Guide to the Routine Management of Asthma in Primary Care. Primary Care Respiratory Society UK. Version 4.0. 2008, revised 2015. https://pcrs-uk.org/sites/pcrs-uk.org/files/AsthmaGuide_FINAL_2015.pdf