Wheeze Clinic: Reducing Avoidable Deaths from Asthma

This case study focuses on bringing secondary expertise into primary care in the management of asthma, particularly for children and young people.

Background

In 2014, a National Bundle of Care was produced to prevent avoidable exacerbations and deaths from asthma.

The recommendation was made following the National Review of Asthma Deaths, which found that in nearly half of the deaths studied (47%), patients dying from asthma hadn’t sought medical help. More than half weren’t under specialist supervision in the 12 months before death (57%).

The study also found that twenty-one per cent of people who died had been seen in a hospital emergency department in the last year. 1 in 10 died from asthma within 28 days or being discharged from hospital.

To combat this, the National Bundle of Care should:

• Review triggers
• Review adherence of prescribed medication
• Review inhaler technique
• Include a planned community follow-up within 48 hours
• Include a Personalised Asthma Action Plan (PAAP) and
• Provide adequate safety netting outlining steps to be taken should the CYP deteriorate again following discharge – approximately 5% of discharged patients re-attend following a relapse of symptoms.

Ten Years Later

A study in 2024 examined the impact of the Bundle of Care over 10 years. It revealed some worrying figures.

12,000 people have died from asthma since 2014. Asthma-related deaths had increased by 25%, despite the recommendations of the National Bundle of Care.

Nearly 7 in 10 people with asthma (69%) weren’t receiving basic care – regular reviews, inhaler technique checks, or written asthma action plans.

Overuse of reliever inhalers was highlighted in the report as a key indicator of poorly controlled asthma, which puts people at greater risk of death.

Additionally, follow-up care is woefully inadequate, with a recent study showing that four in five (82%) people are not getting an appointment with a GP, AHP or Nurse within the recommended 48 working hours after an emergency admission, when they are most at risk of another serious attack.

Demands on Primary Care services are heavy, and booking short-notice appointments is often difficult.

The Project: A Designated Wheeze Clinic

The project is the idea of Catherine Leonard, a Advanced Paediatric Nurse Practitioner, working in Gosforth and Jesmond.

Catherine has experience of working in secondary care and valuable knowledge of how viral wheeze and exacerbation of asthma present. She is also extremely familiar with the severity of illness children and young people can present with and the challenges families face when discharged from hospital.

A designated wheeze clinic in Primary Care would allow Catherine the opportunity to provide solutions to some of the problems outlined in the 2024 report.

How the Clinic Operates

Catherine has regular slots that patients can be booked into, either by staff at the GP practices in the PCN, or by colleagues who see patients in our Same Day Access clinic.

Children aged between 1 and 16 years old can be seen.

Each appointment is a 45-minute slot, allowing Catherine and the patient, often with a family member or carer, the chance to fully review how their asthma is managed and what improvements can be made.

The longer sessions allow time to be spent developing Personalised Asthma Action Plans (PAAP), demonstrating the correct inhaler technique, and reviewing symptom control. The plans are given to parents, schools and other care givers, providing guidance on how to help the child or young person control their asthma, and what to do and who to contact in the event of an exacerbation.

The aim is to work in partnership with patients to help develop a treatment plan which works for them and increases their quality of life. 

Understanding Concerns and Educating Patients

An important part of asthma management is understanding people’s concerns, but also the depth of their knowledge of the condition.

Catherine has heard concerns from parents and children that show some of misconceptions and barriers to effective asthma management.

“We’ve been told different things by different Doctors, who do we listen to?”

“What if it happens again? Who do we contact?”

“Can I still play sports and go out with my friends”

“Spacers aren’t cool – I’m not carrying that around with me”

‘”I’m worried school won’t believe me when I say I’m finding it hard to breathe – they take our inhalers and lock them away“

Outcomes

A total of 48 patients have been seen over the course of 53 individual appointments. All of those patients now have full Personalised Asthma Action Plans

The project is young and runs on a small scale. Catherine has four available slots one morning a week, with no cover when she isn’t working.

Because of that, the statistical impact is difficult to measure, but the following snapshots of patient experience point to the impact the Wheeze Clinic can have.

Patient Snap Shots

These snapshots are based on real patients, but don’t use their real names.

Alfie

Twelve-year-old Alfie attended the Same Day Access clinic with a dry cough he’d had for months. It was worse at night and first thing in the morning, and he would sometimes feel short of breath when running around with his friends.

He suffers from mild hay fever, and was given a ‘blue inhaler years ago – but can’t really remember why’.

Catherine started Alfie on an ICS inhaler BD with Ventolin Reliever PRN, and booked a return appointment to the Wheeze Clinic 6 weeks later,

When Catherine saw Alfie again, he had responded well to the ICS, and had rarely needed the Ventolin after two weeks of use.

His cough was gone, sleep was improved and was able to enjoy sports again without suffering shortness of breath.

The ‘spacer’ was still an issue though. Alfie hated it – “I’m already different, I don’t want to be more different”.

Catherine understood this was a real barrier, and together they agreed to move to the MART regime, using one inhaler as both the preventer and reliever, removing the need for the spacer. After being shown the technique, Alfie was much happier.

Copies of his PAAP were updated, and given to his parents, school and Grandparents, where Alfie spends time. The plans include what to do and who to contact in the event of an escalation.

Liam

Liam is 15, a known asthmatic with severe eczema, who has been seen regularly in the Same Day Access clinic. He’d also been admitted twice in 3 months with exacerbations of asthma symptoms.

During one admission, he needed resuscitation in A&E, followed by IV drugs and several days of oxygen.

He was identified as not using ICS as prescribed and only the reliever inhaler when he felt symptoms. The reliever, however, was found to be empty.

Liam didn’t come to his first schedule Wheeze Clinic appointment, and has a history of not attending appointments elsewhere too.

When we did attend with his mother, he didn’t really engage or fully appreciate the seriousness of his condition – “I got better, didn’t I?”

Fundamentally, Liam didn’t understand what asthma was doing to his body, nor that it could potentially kill him.

This flicked a switch, and he was more engaged after that. Catherine discussed with him how to properly use each inhaler and that they were for different things. The appointment helped him to see the need for maintenance therapy. Together they decided on a plan that wold work for him.

When Liam’s asthma was reviewed in a separate Same Day Access appointment, Liam was taking managing his asthma more seriously.

“I did not realise Asthma was so serious until you told me that – no one has ever said that to me before – I make sure I take my inhalers as you told me and I make sure my Mam gets my new ones before they run out.”

What’s next for the Wheeze Clinic?

In the first instance, the plan is for Catherine to continue the clinic, and further embed it into the workings of the GP practices in the network.

Catherine has been able to develop some new skills and improve her knowledge, and hopes to be able to continue to share her expertise with patients and colleagues.

There are potential opportunities to explore around linking up with hospital discharge teams to automatically refer people for their 48-hour follow-up after leaving hospital, and possibly even exploring the need for better understanding of asthma in schools and further through education.