Patterns and management of early life asthma and wheeze


Background: The incidence and prevalence of asthma among Bradford children is high, and poorly controlled asthma can be life-threatening.  Asthma is one of the commonest reasons for urgent admissions to secondary care among children in Bradford, accounting for around 30% of the total.  Carers are using emergency hospital care more and more as their initial health provider and there is a steady rise in A&E attendances.  Unplanned admissions to hospital result in considerable stress for the child and family, and they are also costly, both for the family and the wider health economy.

We know that acute exacerbations of asthma requiring hospital admission could be prevented in approximately 75% of cases, but at present only around 20% of children with asthma receive all the elements of clinical care that they require to manage their condition successfully.  In addition, there is a variation in how children present to health care services and how they are managed by the professionals they see.  In Bradford, there is a system wide guideline for asthma management in children that has been agreed across primary and secondary care and education.  It is based on BTS guidelines.  However, the complexity and variety of city-wide health systems and patient pathways has previously made it difficult to gather data to understand exactly how real care might differ from the guidelines.

Commissioners and providers in Bradford agree that ‘The key to delivering effective emergency and urgent care is ensuring that the whole system is designed to support self-care and community care at home, thereby reducing avoidable hospital admissions and facilitating timely early discharges’ a quote from the Institute for Innovation and Improvement.  This ethos is reflected in the Royal College of Paediatrics and Child Health 2015 publication, ‘Facing The Future: Together For Child Health’, which states, “No child should be in hospital when care can be provided to an equivalent or better standard outside the hospital in their locality and closer to their home if appropriate (right care, right time and right place)”.

Linked, routine electronic data offers a new opportunity to understand the whole patient pathway for urgent care in children with asthma, and use this understanding to design services that support self-care at home and reduce unnecessary hospital admissions.

 

Aims: To use linked, routine electronic healthcare data to help improve the urgent care pathway for paediatric asthma, so that more care is provided in the community and unplanned hospital admissions are reduced


Progress: A new pathway will be implemented in Autumn 2017 to provide more urgent care for children with asthma in the community, rather than hospital (step-up and step-down care).  Linked, routine electronic data from the Connected Bradford project will be used to evaluate the change in pathway, by providing a whole-system, linked dataset for the service.


Plans

 1.     Map and model the current pathway for urgent asthma care in children across Bradford, using routine linked data, to identify potential pathway targets for improvement.


2.     Work with local stakeholders using linked, whole pathway data as a measurement for tests of change to the pathway for urgent paediatric asthma care.


3.     Explore associations between routine data parameters in the community (such as prescription data) and subsequent unplanned hospital admission with asthma.  To use any identified associations as the basis for an electronic decision support tool designed to help reduce emergency admissions.



Located at Bradford Teaching Hospitals NHS FT and linked to our Healthy Children and Healthy Families Theme, a new ambulatory care project for children and young people (ACE) has been running since 2017.  Since the launch of the wheezy child/ asthma pathway, we have accepted 250 referrals of children with wheeze/asthma and have saved approximately 300 bed days. Over 85% of referrals to ACE have been managed in the community whereas before they would have been seen and managed in hospital. The majority-nearly 60% of our referrals- have come from primary care. There have been no adverse events and feedback (received from 25% of our families) has all been very positive.

 A recent comment from a parent: ‘’Thank You!  A wonderful Service.  We had a GP appointment where she told us we would have to go to the hospital.  I panicked a bit as I had another child at school to consider (how he would be picked up), no change for parking and no food with me to take - all on top of worrying about how my little boy was breathing.  When this service was suggested by the on call paediatrician it was a huge relief.  We couldn't have asked for better care.’’

 Each pathway comes with its own ‘care bundle’ delivered by an ACE nurse in the home. This means for wheeze/asthma each child receives all the care processes recommended by BTS and Asthma UK. This is to ensure that all children and young people receive appropriate health education and health promotion. 

 ACE has resulted in greater collaboration across community and secondary care services and has been possible because of the development of new clinical roles within nursing and medical teams. It has been the model to trial other innovative shared system wide clinical pathways. It is hoped that the service will be replicated in other areas. If you would like to know more please visit us at https://www.bradfordhospitals.nhs.uk/the-ace-service/