This first confidential enquiry report from the Royal College of Physicians (RCP), Why asthma still kills, published recently, found nearly half (45%, 87 patients) of those included in this study who died from asthma did not have any medical help during the final asthma attack. For 33% of people (65 patients) there was no record of them seeking medical assistance and for 11% (22 patients) help was not given in time. The NRAD found that 80% of the children under 10 (8/10), and 72% of young people aged 10–19 (13/18) died before they reached hospital.
The NRAD was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the RCP in collaboration with professional and patient organisations. The NRAD looked at the circumstances surrounding death from asthma in order to identify patterns and trends in the care received by patients.
Improvements are needed so that both patients and healthcare professionals are better at recognising the signs of deterioration in asthma, and are better at acting quickly when faced with a potentially fatal asthma attack.
Findings from the NRAD include:
•The standard of care received was less than satisfactory in a quarter of those who died and there was ‘room for improvement’ in the care received by 83% of those who died.
•Triggers for asthma attacks had not been documented in more than half of the cases and 57% were not recorded as being under specialist supervision in the year before death.
•There were deficiencies in both routine care and in the treatment of attacks.
•There was widespread under-use of preventer inhalers and excessive over-reliance on reliever inhalers.
•10% of those who died did so within one month of discharge from hospital following treatment for asthma; at least 21% had attended an emergency department at least once in the previous year.
•Over half of those who died were being treated for mild or moderate asthma at the time; experts concluded that this was mostly because neither doctors nor patients themselves recognised how serious their asthma really was.
•19% of those who died were smokers and others, including many children, were exposed to second-hand smoke in the home.
•Some patients had not collected their prescriptions for preventative treatment or did not attend regular asthma check-ups.
Recommendations made by the NRAD include:
•Every hospital and GP practice should have a designated, named clinician for asthma services.
•Better monitoring of asthma control; where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up.
•Better education is needed for doctors, nurses, patients and carers to make them aware of the risks. They need to be able to recognise the warning signs of poor asthma control and know what to do during an attack.
•All patients should be provided with a personal asthma action plan (PAAP), which can help them to identify if their asthma is worsening and tell them how and when to seek help.
Dr Kevin Stewart, clinical director, Clinical Effectiveness and Evaluation Unit (CEEU) at the RCP said: "It’s time to end our complacency about asthma, which can, and does, kill. There are important messages in this report for clinicians, for patients and their families and for policy-makers. We haven’t paid enough attention to the importance of good routine asthma care by clinicians with the right training and experience, and the part that patients themselves play in this. Too often we have also been slow to detect signs of poor asthma control and slow to act when these have been present, with tragic consequences for some families. We can and we must do better."
Dr Anita Donley, clinical vice president at the RCP said: "Why asthma still kills and the National review of asthma deaths confidential enquiry has shown that there are deficiencies in routine care for patients with asthma. Doctors and nurses are not recognising the risk of dying from an asthma attack, even for patients with mild or moderate asthma. This complacency must end and care must change if we are to reduce the number of patients dying from asthma. The review calls for a designated clinician with responsibility for asthma care in each hospital and GP surgery. We need to ensure there is provision of staff and training and education in hospitals in order to escalate treatment of patients admitted to hospital with a severe asthma attack and who may be at risk of death. Self-management is important in asthma and it is vital that we as healthcare professionals support patients in the education and management of their asthma so that they can control it and recognise when it becomes potentially life-threatening."