Download National Review of Asthma Deaths - Mark Levy

Dr Mark L Levy
FRCGP
• General Practitioner &
Respiratory Lead Harrow
• Clinical Lead National
Review of Asthma Deaths
• Executive Board Member
GINA
[email protected]
www.consultmarklevy.com
@bigcatdoc
www.animalswild.com
Why asthma still kills
National Review of Asthma
Deaths (NRAD) www.rcplondon.ac.uk/NRAD
What are the lessons we’ve
learnt?
Mark L Levy
Clinical Lead, NRAD (2011-2014)
Case review 1 (from a number of cases for annonymity)
• Female with late onset asthma
• Confirmation of diagnosis delayed - after many months on
therapy with intermittent salbutamol (28% reversibility on
spirometry)
•
Low dose inhaled corticosteroids (beclometasone 100mcg prescribed
• She had a poor attendance record
• Asthma review with practice nurse:
•
•
Waking at night; daytime symptoms and asthma limited her lifestyle
Px last 12 months: 16 salbutamol inhalers; 1 beclometasone inhaler
• She was advised by the nurse to make an appointment to see
the doctor without any advice or changes in the treatment ;
no record of a PAAP
• The patient died 8 weeks later without ever making an
appointment to be seen
Case history – from a few cases to preserve
confidentiality
•
•
•
•
•
male died age 6 - asthma diagnosed in 3rd year
PICU - life threatening asthma attack
1X Follow up by paediatrician
– failed 2X OPD - discharged from care (Trust policy)
seen by his GP URTI:
•
•
•
•
•
red and inflamed throat
chest was clear with very little wheeze but cough ++
no record of any vital signs or SaO2
salbutamol 2 puffs up to 4 times daily prn; Amoxicillin125mg tds, and a
volumatic
Died 10 days later – pre-hospital cardiac arrest - status
asthmaticus on Post Mortem
Case history – from a few cases to preserve
confidentiality – 6yr old male
At the time of death : not using asthma medication
•His last prescription - 3/12 before death
• Formoterol easyhaler
•Previous 12/12:
• Salbutamol – 12 inhalers; Seretide 50/25 – 1 inhaler;
• Formoterol – 2 inhalers; Qvar – 1 inhaler and
• Montelukast – 2 prescriptions (1 month supply each)
Points:
Neither hosp or GP taking the responsibility to follow this child up who had
fallen between the hospital and the GP (?? Trust policy)
‘At-risk’ status not recognised
Failure to take appropriate medication and attend follow-up appointments
asthma review / no personal asthma action plan / ? child protection issues
National Review of Asthma Deaths (NRAD)
Key Messages
• Diagnosis (Asthma/COPD)
• Failure to call for or get help (45%)
• 77% no PAAP
• Failure to recognise danger signals
• Excess relievers/insufficient ICS
• Failure to follow up after attacks
• Failure to appreciate that asthma is a
chronic illness – assess and optimise!
Overall aim of NRAD
The aim of the NRAD was to understand the
circumstances surrounding asthma deaths in
the UK, in order to identify avoidable factors
and make recommendations for changes to
improve asthma care as well as patient selfmanagement
(This was not a prevalence study – did not aim to determine
the number of asthma deaths in the UK)
www.rcplondon.ac.uk/nrad
Underlying cause of death
On the basis of what is written on the Medical Certificate of the
Cause of Death (MCCD), the Office for National Statistics (ONS),
National Records of Scotland (NRS), Northern Ireland Statistics and
Research Agency (NISRA) then determine the underlying cause of
death. Based on the formula used world wide for this purpose International Classification of Disease (ICD-10)
So where an MCCD reads:
Ia Respiratory Failure
Ib Asthma
Ic Chest infection
Ia Chest infection
OR
II Asthma, IBS, Liver
failure, sepsis
The underlying cause of death (UCD) is determined to be Asthma
The underlying cause of death (UCD) is also Asthma
NRAD Notification
(Section 251 of the NHS Act 2006)
Office for National Statistics
(ONS); National Records of
Scotland (NRS); Northern
Ireland Statistics and
Research Agency (NISRA).
NRAD Website
- Clinicians
- Families / Friends
- Coroners
- Local co-ordinators
(374 in 297 Hospitals)
www.rcplondon.ac.uk/nrad
NRAD flow diagram - 1
Asthma mentions
MCCD* (3544)
Excluded – not underlying
cause of death or >75 and
asthma in part II (2644)
Included
(900) – 38 CYP
* MCCD= Medical Certificate of Cause of Death
www.rcplondon.ac.uk/nrad
Clinical information requested for
final 2 years (n=900)
– ALL CONSULTATIONS
– ALL CORRESPONDENCE
– ALL PRESCRIPTIONS (ACUTE &
REPEAT)
– PM/CORONERS
REPORT/AMBULANCE
– COPIES OF ANY LOCAL REVIEWS
www.rcplondon.ac.uk/nrad
NRAD flow diagram - 2
Asthma mentions MCCD
(3544)
Excluded – not underlying
cause of death or >75 and
asthma in part II (2644)
Included (900)
Clinical Lead
& Expert panel
276/900 included for panel discussion
www.rcplondon.ac.uk/nrad
Multidisciplinary confidential
enquiry panels
•
•
•
•
•
•
37 panel meetings
174 volunteer assessors
6 -10 cases per panel
Two assessors per case
Panel assessment form
Consensus agreement
• 195/276 died from asthma
• 1000 panel recommendations
• Major factors in 60% deaths potentially avoidable
www.rcplondon.ac.uk/nrad
Patients
Duration of asthma (n=104) :
0-62 yrs (Median 11 yrs)
Age at diagnosis (n=102) : 10 mths – 90 yrs (Median 37 yrs)
Age at death (n=193) :
4 yrs – 97 yrs (Median 58 yrs)
Severity of asthma (n=155):
(classified by the Clinicians)
Mild
Moderate
Severe
14 (9%)
76 (49%)
61 (39%)
12/28 (42%) of children/YP were thought to have mild/mod asthma
Definition of severity of asthma:
‘Amount of treatment required to gain control
of the asthma’
37 (19%) - had assessment of asthma control
European respiratory Journal 2008;32(3):545-54
6th May 2014
www.ginasthma.org
www.consultmarklevy.com
GINA assessment of symptom control
Level of asthma
symptom control
Symptoms
In the past 4 weeks, has the patient had:
• Daytime asthma symptoms
more than twice/week?
Yes No
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice/week?
Yes No
• Any activity limitation due to
asthma?
Yes No
WellPartly
Uncontrolled
controlled controlled
None of
these
1-2 of
these
*Excludes reliever taken before exercise, because many people take this routinely
GINA 2014, Box 2-2A
3-4 of
these
GINA 2014,
Box 2-2
Misuse of corticosteroid metered-dose inhaler is
associated with decreased asthma stability
AIS = Asthma
Instability
Score
Giraud, European respiratory Journal. 2002;19(2):246-51
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Results of the first (before training), and second
and third Vitalograph Aerosol Inhalation Monitor
(AIM) tests after training
Levy et al, Prim Care Respir J 2013;22(4):406-411
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pMDI technique using the Vitalograph
Aerosol Inhalation Monitor (AIM) and
GINA Control
Levy et al, Prim Care Respir J 2013;22(4):406-411
www.consultmarklevy.com
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pMDI with and without spacer and
GINA Control
GINA Control
Controlled
Partly Controlled
Uncontrolled
Total
pMDI with and without spacer and GINA control
BDP pMDI
BDP pMDI with
Total
spacer
508(51%)
75(68%)
583
332(33%)
33(30%)
365
164(16%)
2(20%)
166
1004
110
1114
Levy et al, Prim Care Respir J 2013;22(4):406-411
www.consultmarklevy.com
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GINA control vs BDP pMDI (Clenil and
QVAR) vs QVAR Easi-Breathe
GINA Control
BDP pMDIs
Controlled
Partly Controlled
Uncontrolled
Total
597(46%)
417(32%)
283(22%)
1297
BDP pMDIs
QVAR EasiBreathe
102(64%)
45(28%)
13(8%)
160
Levy et al, Prim Care Respir J 2013;22(4):406-411
Total
699(48%)
462(32%)
296(20%)
1457
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The control-based asthma management cycle
NEW!
GINA 2014, Box 3-2
© Global Initiative for Asthma
Excess use of beta-agonists
(SABA)
www.consultmarklevy.com
Asthma consultation = opportunity to
reduce risk
Sheriff Kelly said that Emma's death
might have been avoided if the
consultant paediatrician at Yorkhill
Hospital in Glasgow and her GP or
pharmacist had acted differently.
Review dose inhaled steroids in children
www.consultmarklevy.com
Prescribing
NRAD Recommendation:
Electronic surveillance of prescribing in primary
care to alert clinicians and pharmacists excessive Short Acting Beta-Agonist
Bronchodilators (SABAs) or too few preventers
Practices
(denominator = 138 except where mentioned otherwise)
Median 4 Doctors/practice (n=131); median 9000 patients
Quality Outcomes Framework (QOF) data (n=89)
• Full points 74/89 (83%)
Asthma reviews - performed by:
• 78/136 (57%) GPs
• 3 (2%) GP with Special Interest
• 82 (60%) Nurses with diploma
• 62 (46%) nurses without asthma diplomas *
www.rcplondon.ac.uk/nrad
Main conclusions for the 276 cases
considered by panels
People who died from asthma
People who had asthma but did not die from it
People who did not have asthma
Insufficient information:
- To decide whether the person had asthma
- To decide whether the person died of asthma
195 (71)
36 (13)
27 (10)
14 (5)
4 (1)
Diagnosis of asthma, COPD and
asthma-COPD overlap syndrome
(ACOS)
A joint project of GINA and GOLD
GINA Global Strategy for Asthma Management
and Prevention
GOLD Global Strategy for Diagnosis,
Management and Prevention of COPD
GINA 2014
© Global Initiative for Asthma3.
GINA
2014, Box 5-4
GINA
2014
© Global Initiative for Asthma
Quality of Care – Panel Conclusions
Conclusion
All ages
(195)
0-19
(28)
Chronic Management
- Adequate
56 (29%)
2 (7%)
Previous Attack Management
- Adequate
69 (35%)
8 (29%)
Final Attack Management
- Adequate
66 (34%)
13 (46%)
Overall Standard of Asthma Care
- Good practice
31 (16%)
1 (4%)
Major factors identified by panels
(i.e. contributed significantly to the deaths, where different management
would reasonably be expected to have affected the outcome )
Did not recognise high-risk status
Lack of specific asthma expertise
Did not perform adequate asthma review
Did not refer to another appropriate team member
Failure to take appropriate medication in month before death
Failure to take appropriate medication in year before death
Over prescribed short acting beta agonist bronchodilator
Poor or inadequate implementation of policy/pathway/protocol
Lack of knowledge of guidelines
Did not adhere to medical advice
www.rcplondon.ac.uk/nrad
n
21
17
16
16
15
13
13
13
12
10
Potential avoidable factors identified by panels in
recognition of risk status
Primary Care
< 10 yrs
10-19 yrs
N=10
N=18
n(%)
n(%)
One or more
avoidable factors
Delay in
recognising Risk
status
Quality of
assessment
Did not diagnose
or recognise high
risk status
Secondary Care
< 10 yrs
10-19 yrs
N=7
N=9
n(%)
n(%)
7(70)
15(83)
2(29)
3(33)
5(50)
9(50)
0(0)
2(22)
6(60)
14(78)
2 (29)
1 (11)
5 (50)
13 (72)
2 (29)
1 (11)
The panels identified potential avoidable factors
related to the assessment of the final attack
Primary
Care (n=38)
n(%)
≥ 1 factors
13(34)
Secondary < 10 yrs Sec Care
Care (n=59)
(n=2)
n(%)
n(%)
20(34)
1(50)
10-19 yrs Sec
Care (n=5)
n(%)
1(20)
NRAD Recommendation:
• Every NHS hospital and general practice - clinical lead for asthma services
responsible for formal training in acute asthma care
The panels identified potential avoidable factors
related to the management of the final attack
≥ 1 factors
Primary Care
(n=38)
n(%)
Secondary Care
(n=59)
n(%)
< 10 sec care
(n=2)
n(%)
10-19 prim care
(n=1)
n(%)
10-19 sec care
(n=5)
n(%)
12(32)
20(34)
1(50)
1(100)
2(40)
• Delay or failure : to initiate treatment / to follow guidelines
• Use of NIV in acute severe asthma
• Failure to recognise risk features (High normal pCO2 levels)
NRAD Recommendation:
• Every NHS hospital and general practice - clinical lead for asthma services
responsible for formal training in acute asthma care
• The use of patient-held ‘rescue’ medications should be considered for all
patients who have had a life-threatening asthma attack or a near fatal
episode
The panels identified potential avoidable
factors related to follow-up after attacks
•
•
•
19/195 (10%) died within 28 days of hospital discharge for asthma attack
In 13/19 (68%) potentially avoidable factors
• discharge into the community
• follow-up arrangements
At least 40 (21%) attended an emergency department (ED) with an
asthma attack in the previous year (23 ≥ 2 occasions)
NRAD Recommendations – follow-up and referral:
• Follow-up after every attendance for an asthma attack
• Secondary care follow-up - after every hospital admission for asthma,
and after two or more ED visits with an asthma attack in 12 mths
• Patients with > 2 courses systemic corticosteroids or on BTS step 4/5
must be referred to a specialist asthma service
Whqt cqn we do?
• Change system (? More specialist involvement)
• Review Diagnoses (Asthma, COPD & ACOS)
• Identification and reduction of risk
• Current control AND future risk
• Admissions & ED attendances
• Prescriptions (Salbutamol & ICS)
• Educate colleagues and patients
• Implement guidelines (& change them)
• PAAPs
• Improve quality of death certification
Levy ML, Winter R. Asthma deaths: what now? Thorax
Feb 2015
Levy ML, The National Review of Asthma Deaths –
what did we learn and what needs to change?
Breathe, March 2015
www.consultmarklevy.com
Post attack review
www.consultmarklevy.com
Key recommendations
1: Organisation of NHS services
• Every NHS hospital and general practice - clinical lead for
asthma services
• Patients with > 2 courses systemic corticosteroids or on BTS
step 4/5 must be referred to a specialist asthma service
• Follow-up arrangements :
•
•
after every attendance for an asthma attack
Secondary care follow-up - after every hospital admission for asthma,
and after two or more times ED visits with an asthma attack in 12 mths
• A standard national asthma template
• Electronic surveillance of prescribing in primary care to alert
clinicians (excessive SABAs or too few preventers
• A national ongoing audit of asthma
Key recommendations
2: Medical and Professional Care
• All people with asthma -personal asthma action plan (PAAP)
• Structured review by a healthcare professional with specialist
training in asthma, at least annually
• Factors that trigger or make asthma worse must be elicited
routinely and documented in the medical records and
personal asthma action plans (PAAPs)
• Assess asthma control at every asthma review. Where loss of
control is identified, immediate action is required including
escalation of responsibility, treatment change and
arrangements for follow-up
• Aware of the features that increase the risk of asthma attacks
and death, including the significance of concurrent
psychological and mental health issues
Key recommendations
3: Prescribing and medicines use
• Patients prescribed > 12 SABAs in 12 mths - for urgent
review of their asthma control
• An assessment of inhaler technique - routinely undertaken
and also checked by the pharmacist
• Monitor non-adherence with preventers
• Where long-acting beta agonist bronchodilators are
prescribed for people with asthma - should be in a single
combination inhaler
Key recommendations
4: Patient factors and perception of risk
• Patient self-management should be encouraged to reflect
their known triggers (increase Rx before the start of the hay
fever season, avoiding NSAIDs, early use of oral
corticosteroids with viral or allergic-induced exacerbations)
• Smoking and/or exposure to second-hand smoke documented & offer referral
• Parents and children, and those who care for or teach them,
should be educated about managing asthma. This should
include emphasis on ‘how’, ‘why’ and ‘when’ they should use
their asthma medications, recognising when asthma is not
controlled and knowing when and how to seek emergency
advice
• Efforts to minimise exposure to allergens and second-hand
smoke should be emphasised especially in young people with
asthma
Supporting partners
Eastern Region
Confidential Enquiry
of Asthma Deaths
Acknowledgements
Colleagues on the NRAD Core team
Rachael Andrews
Hannah Evans
Jenny Gingles
Debora Miller
Rosie Houston
Navin Puri
Laura Searle
Programme coordinator
Medical statistician
Northern Ireland
Northern Ireland
Programme manager (until February2013)
Programme manager (from February 2013)
Program Administrator (until October 2013)
Strategic Advisory Group (Robert Winter) ; RCP Rhona Buckingham & Kevin
Stewart (CEEU)
Steering Group (Derek Lowe) ; Expert Advisors ; Panel members ; Hospital coordinators ; HQIP (Jenny Mooney) ; Hannah Bristow (RCP Press Team)
Craig Bell (Scotland), Jenny Gingles (NI) and Karen Gully (Wales)
Writers group – Caia Francis, Shuaib Nasser, Jimmy Paton and Mike Thomas
Those who died from asthma & the clinicians who returned data