Integrated Care Pathway (ICP) for Asthma: A Tool to Provide Seamless Care

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Integrated Care Pathway (ICP) for Asthma A Tool
to Provide Seamless Care

• Arvind Shah
• Consultant Paediatrician Lead clinician
• North Middlesex University Hospital

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Contents

• Asthma ICP for Emergency Department (ED)- study
• Asthma ICP for in-patient management
• Asthma ICP for primary care
• Conclusion
• References
• Acknowledgments

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Asthma ICP for ED- Study
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The Asthma Integrated Care Pathway in the
Emergency Department- A tool to prevent hospital
admission?A retrospective non-randomised
controlled studyOral presentation European
Respiratory Society Vienna,16th September
09 Sherine DewlettArvind Shah Pallavi
Pillai Cally Tann
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Introduction

• Acute asthma is a major source of hospital
  admission and is increasing
• Management in the Emergency Department (ED)
  varies and does not always follow evidence based
  guidelines
• The Asthma Integrated Care Pathway (ICP) is a
  document which guides asthma management in the ED
  according to BTS guidelines
• Promotes good clinical practice, standardises
  management, multidisciplinary care, communication
  and education

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The Asthma Integrated Care pathway (ICP)
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Study aims

• To find out if implementing an asthma ICP in the
  ED can improve asthma management and reduce
  hospital admission

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Methods

• Design Retrospective, non-randomised study
  comparing management in those with ICP and
  without ICP
• Setting North Middlesex ED
• Population Ages 5-16 with asthma
• Exclusion criteria Life threatening asthma,
  alternative diagnoses
• Intervention Asthma ICP Control no ICP
• Study periods 3 periods-results collated
• April-June 2007
• August-October 2007
• October-December 2008

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Methods

• Data collection
• 1. Patient demographics age and sex distribution
• 2. Severity of asthma mild, moderate, severe
• 3. Treatment given
• 4. If ICP was used (ICP)
• 5. Admission rates
• 6. Further analysis of admissions
• Primary Outcome Admission rates
• Secondary Outcomes Asthma management
• Statistical analysis Odds ratios with 95
  confidence intervals

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Results- Use of ICP in the ED

• 351 children seen in 9 month period after 41
  excluded
• 130 used ICP (37)
• 221 no ICP used (63)
• Non-randomised

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Patient demographics
Sex
AgAge

• 5 -8 140 (56 ICP)
• 9 -12 119 (44 ICP)
• 13-15 92 (30 ICP)

• 212 boys (82 ICP)
• 139 girls (48 ICP)

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Severity of asthma

• 224 mild (78 ICP)
• 98 moderate (41ICP)
• 27 severe (13ICP)
• 2 life threatening (ICP not applicable)

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Total Admissions

• 37 admitted
• 2 life threatening ICP not applicable
• 6 admitted with ICP
• 29 admitted without ICP

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Comparison of admission rate with/without ICP
Without ICP 13.2 (29/221) admitted
With ICP 4.6 (6/130) admitted
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Severity of admissions

• 0 mild
• 17 moderate (1 ICP)
• 18 severe (5 ICP)
• 2 life threatening(ICP N/A)

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Admission rates with/without ICP and statistical
analysis

• - ICP ICP
• Total 13.2 4.6
• Moderate 27 3
• Severe 93 38
• Odds ratios (95 Confidence Intervals)
• -ICP ICP
• Total 3.1(1.3-7.8) 0.3 (0.2-0.8)
• Moderate 16(2-123) 0.06(0.01-0.5)
• Severe 21(2-211) 0.05(0.01 -0.5)

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Further analysis of admissions

• 11 of 37 admissions deviated from guidelines
• 5 inadequate steroid dose 20mg vs 40mg
• 2 only 1 neb given when satslt92
• 3 inadequate salbutamol dose 2.5mg vs 5mg
• 1 inhaler given when sats lt92
• Up to 27 of admissions without ICP may have been
  preventable

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General management of asthma in the ED

• Treatment given ICP no ICP
• Steroids given 100 94
• x3 nebs when sats lt92 100 87
• inhalers given sats gt92 92 40
• correct steroid dose 100 78
• correct neb dose 100 84

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Summary of findings

• ICP may reduce admission and improve asthma
  management in the ED
• Potential reduction of up to 27
• Statistically significant reduction in admission
  rates (4.6 Vs 13.2 - OR 3.1)
• Marked reduction seen in moderatesevere asthma
  exacerbations
• Low implementation rate of 37 which we need to
  improve to see full impact of ICP

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Limitations and further study

• Non-randomised
• Selection bias
• Confounding
• Retrospective and non-blinded
• 3 study periods- learning and dilution effect
• Secondary outcomes Time to first
  nebuliser/steroid, effect of education,
  communication, re-presentation, cost analysis
• Evaluation of Community/Inpatient ICP

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Asthma ICP for In-Patient Management
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New NMUH Asthma Clinical Pathway
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Written asthma management plan

• There are two pre-prepared asthma management
  plans
• 2-5 year olds
• gt5 years
• The pre-prepared asthma management plans explain
  the symptoms that the child/parent needs to look
  out for as a sign of deteriorating asthma
• Need to individually tailor the pre-written
  handouts for each patient so that they know what
  action to take

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Asthma management plan for 2-5 yr olds
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Asthma management plan for children aged 5 years
and above
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Asthma ICP for Primary Care
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• Identified issues
• When to reassess (30-60 min?) how long to keep
  the child with moderate asthma attack (30-120
  min?)
• Dose of Prednisolone 30mg 5-10 years 40mg
  above 10 years
• Moderate - severe asthma attack Role of IV
  hydrocortisone
• Practical issue about documentation
• Consider small investment i.e. pulse oximeter
• Role of asthma nurses

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Conclusion

• We have designed, developed and implemented
  simple ICPs in the primary care, ED in-patient
  asthma management settings
• The primary care ICP will reduce hospital
  attendance/admission of children with mild asthma
  exacerbations
• The early study of the ED ICP suggests it can
  improve asthma management and reduce hospital
  admission as well as have other benefits
• The in-patient ICP has the potential to reduce
  the length of hospital stay

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References

• British Thoracic Society guidelines 2007
• Effect of a pathway on hospitalisation rates of
  children with asthma a prospective study
  
  SP Norton et al Arch Dis Child 20079260-66
• Effect of an integrated care pathway on asthma
  care in hospital Cunningham et al. J paediatr
  2008152 (315-20)
• Impact of a clinical pathway on hospital cost and
  length of stay Wazeka et al. Paed Pulmonology
  Vol32, issue 3 211-216
• One year experience with an inpatient Asthma
  Clinical pathway. Kwan Gett et al Arch paed Adol
  Med 1997151(684-689)
• Pediatric Asthma Care in US ED
  Crain et al. Arch
  Pediatric adoles med 1995149(893-901)

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Acknowledgements

• Theresa Coe
• Christina Keating
• Susan Momi
• Natasha Price
• Reema Patel
• Eddie Lamuren

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The Integrated Care Pathway ICP for Children
with Wheeze

• A pilot project within the Leading Workforce
  Transformation programme from NHS London.
• November 2010

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Pilot Project as part of Leading Workforce
Transformation programme, NHS LondonJohn
Chang Consultant Paediatrician, Croydon
University HospitalNatalie Douglas Assistant
Director for Children Families, Hounslow
Richmond Community Healthcare Maria Luscombe
Head of Paediatric Therapy Services, North West
London Hospitals TrustArvind Shah Consultant
Paediatrician, North Middlesex HospitalKaren
Sobey Hudson Project Manager, AHP CPD Lead, NHS
London
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75 of children attending AEs in London did not
require hospital treatment
16, or 112,000 of these children, attended for
wheeze. 2,700 of these were in our local area of
Hounslow
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To develop a workforce model for an integrated
care pathway for children with wheeze, that would
result in delivery of care in the community and a
reduction in AE attendances
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To develop a workforce model for an integrated
care pathway for children suffering from wheeze
which will allow care to be delivered in the
community.

• 14 practices trained on pathway very positive
  feedback
• Each practice given Pulse Oximeter Spirometer
• GPs returning audit forms on asthmatic patients
  followed up every 2 weeks by asthma nurse /
  liaison officer

• Dedicated asthma nurse
• Follows up with every patient attending AE
• Administering parent surveys to understand needs

• Produced new posters on asthma and viral wheeze
  displayed in AE, GP practices, children's
  centres
• Posters accompanied by information leaflets also
  distributed by asthma nurse

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We have collected data from a range of sources to
understand the pathway, patients parents needs
and the effectiveness of interventions
Project results can be easily shared with
Richmond, NW SW clinical working group
Parent survey n49, parent telephone interview
n21, GP interview n6
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Your child unwell wheezy or chesty

• Is she/he blue
• or
• lifeless

• Call 999 or get to AE ASAP
• Administer oxygen if available
• Administer salbutamol 10 puffs via
• spacer whilst waiting for the ambulance

Yes
No

• Arrange to see GP within 48 hours
• unless there are other concerns, in which case
• arrange to be seen in urgent care centre within
• 24 hours

• Can he/she talk, drink, eat
• Looks usual self
• He/She has a moist cough

Yes
No

• Administer treatment as per Intergraded
• Care Pathway (ICP) for asthma

Do He/she have a diagnosis of asthma
Yes
No

• First attack of wheeze
• Short of breath
• Not sure what is wrong with child

• Make appointment to be seen in Urgent care centre

Yes

• Make appointment to see GP within the next 48
  hours.
• Or go to urgent care centre - if condition
  worsens
• (ie off feeds, high fever or more sleepy or
  short of breath )

No
J.Chang,A.Shah,M.Luscombe,N.Douglas.- April 2010.
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Supporting the patient carer
Parent child
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Supporting care deliverers

• Text

Asthma nurse
Parent child
AE Liaison health visitor
Hospital consultant
GPs
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Supporting information givers
48
18 reduction in AE attendances in our pilot
area
With a total value of
8,100 In pilot area
2.1m in London
50,500 in Hounslow
Based on 104 per AE attendance
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The asthma nurse and leaflets / posters have been
effective in changing parent behaviour
90 of parents interviewed after an appt with the
asthma nurse said they felt more confident in
managing their childs wheeze
1
2
86 of parents interviewed after an appt with the
asthma nurse had a better understanding of when
it is appropriate to go to AE
3
The majority of parents retained the leaflet and
said that it gave them more confidence in
self-management of their childs condition
The leaflets are very informative and easy to
understand. They help me decide when it is
appropriate to take my child to the GP, AE or
when to self-manage. - Parent
SOURCE Project surveys interviews
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GPs have a limited role in influencing parents
behaviour
1
88 of parents did not visit the GP before taking
their child to AE
65 of parents said that their main reason for
going to AE was the seriousness of the childs
condition. The average level of anxiousness
was 8.2/10
2
At the end of the day, parents decide where to
take the child. There is a limited role for GPs
unless parents are more engaged and better
educated. - GP in interview
SOURCE Project surveys interviews
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The way forward
Next steps
Lessons learned
Be flexible your assumption might need modifying
CQUIN goal in Hounslow next year
Budget for 2 more asthma nurses to work in other
areas of patch
Ask your users and listed to them
Medical management is only a small part of the
issue solution
More work with information givers (schools,
pharmacy etc.)
Idea to involve community nursing team
GPs are willing to work in partnership
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Thank you for your attention
Arvind.Shah_at_nmh.nhs.uk
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