Asthma research at CUCRH Asthma education in general practice Asthma clinical governance in emergency departments

The third project is a qualitative study investigating the meanings that people attach to their asthma and its effect on use of health services.

All of our asthma projects have been conducted in collaborations with the Geraldton Hospital, Midwest GP Network and, more recently, the Wheatbelt GP Network and Population Health team.

Asthma Self-management Teaching Helping Maintain Appropriate Care in Rural General Practice (ASTHMA Care in Rural General Practice)

For many people diagnosed with asthma, optimal management is an elusive goal.  Patient education in self-management combined with an asthma action plan has been found effective in reducing unscheduled GP visits and emergency department presentations.  However, most patients do not receive this.  This project trialled an intervention conducted at patients’ regular general practice.  The hypothesis was that a brief, structured, individual education session with an asthma action plan would improve indicators of patient self-management.

Six general practices participated.  Patients currently prescribed asthma medication were invited to attend an education session delivered by a practice nurse, who had been given updated training by the regional Asthma Educator or a local asthma educator with an existing relationship with the general practice.  The practice nurses / asthma educators also gave patients an action plan and the GP saw the patient to review the plan and discuss other aspects of asthma management.  Prior to the education session the participants completed a couple of questionnaires on their asthma control and severity. They then had a lung function measurement, and an assessment of their use of metered dose inhalers (MDI), spacers and peak flow meters (PFM).  These measurements were repeated on the same patients 12 months later.  A review of GP and emergency department records in the 12 months prior to and following the initial session noted unscheduled asthma related visits and asthma plan reviews.

Eighty three patients attended an 'asthma clinic' held at their GP surgery in Spring 2007 and completed the baseline questionnaires. In Spring 2008 55 patients returned for another session and completed the questionnaire again. 

Results found a significant difference in adults’ quality-of-life and increased use of MDIs with spacers.  There were marked trends towards improved self-reported asthma control and reduced visits to general practice and emergency departments as a result of exacerbated asthma. These differences failed to achieve a significance level of 0.05% based on paired t-tests.

The findings indicate that the intervention represents an effective form of patient education. Regular asthma education processes in the practices were not capturing all patients with asthma.  Although not quite achieving significance, the education session also reduced the number of asthma related hospital presentations from 12 to 4 per 100 patients, which, if extrapolated to the catchment of the regional hospital, would save $270,000 annually.

The results add to the body of evidence that shows patient education improves asthma self-management and reduces demand on the health care system.  The study also supports strategies that target all people with asthma and not just those using emergency department services.

The full report for this project can be downloaded here

Asthma Clinical Governance Project

The biggest impact that clinical governance makes is to change people’s attitudes and thinking about their organisation and how it functions. Hospitals will become learning organisations, where constructive criticism, cooperative development and inter-professional respect allow successes to be celebrated and mistakes are not considered blameworthy but opportunities for improvement. (The West Australian Council for Safety and Quality in Health Care)

The Asthma Clinical Governance Project was a collaboration to improve patient outcomes across the entire spectrum of preventative, primary, emergency, hospital, discharge and self-managed care in the Midwest and Murchison Health region.

The Asthma Clinical Governance Steering Committee began in April 2003 with clinicians and managers from the Midwest & Murchison Health Region, Mid West Division of General Practice, the Geraldton Regional Aboriginal Medical Service, and CUCRH.
The Committee focuses on four broad areas: best practice; referral procedures; discharge planning and monitoring. For more information and recent findings contact Dr David Whyatt.

Best practice

The area of best practice focuses on the treatment of acute asthma with Salbutamol. Evidence-based best practice is to use a metered dose inhaler (MDI) and spacer to administer the drug, rather than a nebuliser. Use of MDIs and spacers results in fewer side effects and more effective drug delivery. Furthermore, the use of such devices gives the nurse or doctor an opportunity to educate the patient in correct use of the device, improving self-management.
The project developed new Salbutamol Administration Guidelines and gave training in the correct use of MDIs and spacers. As a result, exclusive use of MDIs and spacers to administer Salbutamol in the Geraldton Regional Hospital A&E department increased from less than 10% of occasions of service to approximately 50%.  The aim is to increase this to better than 95%, in line with practice at teaching hospitals such as the Princess Margaret in Perth.

Referral procedures

Several improvements to referral procedures have been made.

• A copy of the Respiratory Triage Form is forwarded to the relevant GP to increase referral rates to GPs after A&E presentation.
• Coordinated discharge procedures, in part encouraged by use of the Respiratory Nursing Care Plan, increase referral rates to Asthma Educators and GPs during hospitalization and after discharge.
• Use of the Asthma/Respiratory Outpatient Management Plan improves coordinated outpatient management.

Discharge planning

ACHS Guidelines suggest that discharged asthma patients should be receiving:

• a follow-up GP appointment,
• a medication plan, and
• an action plan (designed to improve self-management).

Use of the Respiratory Nursing Care Plan improves and monitors the implementation of this practice, and pro-forma action plans are now available on the wards.

Monitoring clinical indicators

Documents designed to improve patient care and information sharing are also the raw data for the Asthma Clinical Governance Database. Accurate data allows for the collection of clinical indicators, in areas including:

• Re-presentations
• Objective assessment
• Discharge planning
• Appropriateness of admission
• Discharge summaries
• Education
• Risk factors
• Variances

Designated staff monitor and feedback reports on these indicators to relevant departments and the Asthma Clinical Governance Steering Committee to ensure the best asthma care is being provided.

What happened next?

The Asthma Clinical Governance Project was an ongoing process and the Steering Committee met every month for several years. Since January 2005, the Committee has increased its representation from clinical staff, reflecting its reduced emphasis on developing information management tools and moving towards improved care.  Importantly, the Steering Committee identified patient education as a priority area and is developing health promotion initiatives.  The asthma education project described above was an outgrowth of the Asthma Clinical Governance Project.