Analysis

How safer clinical practice could prevent needless asthma deaths

More than five million people in the UK have asthma and three people die every day because of the condition – yet 90% of these deaths might be avoidable.

Picture credit: SPL

Asthma UK has published research showing that thousands of people are at risk of having a potentially life-threatening asthma attacks because of unsafe prescribing.

The charity analysed GP data on 94,955 patients with asthma between 2010 and 2013.

Of the sample, 402 patients were found to have been prescribed long-acting reliever medicines without inhaled steroids. Long-acting reliever medicines (usually administered in green inhalers), are used as a ‘rescue’ to help with shortness of breath, and should never be used without a ‘preventer’ steroid medicine (usually administered in a brown inhaler).

Practices need to call in patients who might be at risk – Debby Waddell

This sample figure, if representative of the whole of the UK, suggests around 22,840 people with asthma, 1,903 of whom are children, might have been prescribed reliever medicines without preventer inhalers. This exposes them to heightened risk of death.

The Asthma UK report, Patient Safety Failures in Asthma Care: the Scale of Unsafe Prescribing in the UK, says it is dangerous to use a long-acting reliever inhaler without a steroid preventer inhaler because long-acting reliever medicines only help keep airways open. They do not treat the underlying inflammation and therefore do not prevent future asthma attacks.

It says systems should be in place to prevent this unsafe prescribing and adds that any patients prescribed reliever medicines without inhaled corticosteroid (ICS) should be contacted immediately for an asthma medication review at their GP practice.

Debby Waddell, an independent London-based clinical nurse specialist in asthma and former clinical lead at Asthma UK, says: ‘The United States has taken prescribing seriously and we need to do the same. Practices need to be looking at new systems and calling patients in who might be at risk and checking on their prescriptions.’

She says patients should have annual reviews to discuss their medication and a care plan covering what they should do when they are well, how to recognise when they are getting worse and what to do if they feel at risk of an attack.

Ms Waddell says patients do not often realise the importance of attending reviews, especially if they are feeling well. ‘Anyone with asthma should be taking it seriously,’ she says. ‘There is complacency on both sides, not just from staff. There is an attitude to asthma that it is “only” asthma and that its management is sorted. For many people another asthma attack is potentially fatal.’

Education

Healthcare staff must be fully competent in teaching patients how to use their inhaler, she says.

‘If staff are not teaching it properly then patients leave with poor inhaler technique and that puts them at risk of poor asthma management.’

Tips on reducing risk

Call in all patients who have been prescribed long-acting relievers with no inhaled corticosteroid for an urgent review.

Identify patients who have been prescribed more than 12 short-acting reliever inhalers in a year and call them in for an asthma review in the near future.

Put audits and electronic alert systems in place to prevent poor practice from occurring.

Ensure that all asthma patients have a written asthma action plan and a review at least every 12 months.

Switch from repeat to acute prescribing for asthma so no further automatic prescribing can occur without a review.

Asthma UK’s research is in response to a report published last year by the National Review of Asthma Deaths, which investigated the deaths of 195 people in 2012/13. It found alarming mistakes in prescribing.

The charity wanted to find out how often these prescribing errors happen in the routine care of the general asthma population.

The analysis found a total of 5,032 people – almost 40% – had been prescribed more than 12 short-acting reliever inhalers (usually blue) over a 12-month period and 1,965 people received them without their medications regimen having been reviewed.

The number of reliever inhalers prescribed in excess ranged from 13 to 80 per person in 12 months. Given that six is a clear warning sign of poor asthma control, the prescribed number suggests patients are receiving nearly 13 times more medicine that they need, the report says.

This figure suggests that around 106,742 people with asthma in the UK might have been prescribed excessive amounts of reliever medication without being reviewed.

Matthew Hodson, chair of the Association of Respiratory Nurse Specialists, and a respiratory nurse consultant at Homerton University Hospital NHS Foundation Trust in London, says short-acting reliever inhalers can be prescribed on their own for mild asthma but clinicians should check patients are not overusing them. Anyone using them more than three times per week requires a review.

‘If a patient comes in saying they are using their blue inhaler all the time, that suggests their asthma is uncontrolled and they may need to step up to a steroid as well,’ he says.

Mr Hodson recommends nurses consult the asthma guidelines published jointly by the British Thoracic Society and Scottish Intercollegiate Guidelines Network.

He says nurses should undertake a post-registration course on the condition, including correct diagnosis, management and inhaler technique.

‘Asthma is one of the main long-term conditions that practices have to manage so it is necessary to make sure they are up to date with the most current guidelines,’ says Mr Hodson.

Nurse-led clinic offers multidisciplinary support

The GP practice in Northern Ireland that runs a nurse-led respiratory clinic once a week and has practice pharmacist support, conducts regular reviews with patients with asthma to ensure prescribing is safe.

Following the National Review of Asthma Deaths, the Cuan Family Practice in Portaferry, Co Down, identified 95 patients who were prescribed combination inhalers for their asthma, and reviewed their notes.

Of those, 80 required a review for various reasons, including excess use of reliever inhalers or poor adherence to the preventer inhaler regimen. These patients were contacted for an appointment with their asthma nurse.

Maeve Nesbitt, a practice nurse who leads the clinic, conducts 20-minute assessments of how patients use their inhalers and how often.

‘It may be that their drugs need to be increased or decreased,’ she explains.

She says pharmacists and receptionists flag up any patients who may be seen to be excessively using their reliever inhalers.

But Ms Nesbitt explains that poor adherence with the brown preventer inhaler regimen is also a problem.

‘Educating patients is crucial,’ she says. ‘I often see the lightbulb moment in patients when they see what they need to do. They realise they should be on the preventer inhaler and it is reassuring to see the message is getting through.’

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