13 May 2020
The changing world of the telephone asthma review
I’m writing this on VE day when we’re paying respect to those who lost their lives during the war, and at the same time coming together as a community to support each other in a time of national crisis. I mentioned in my last blog about how I’ve taken inspiration from that time, so I make no apologies for flying the Union Flag from my house today.
No sooner had I posted a picture of me, the flag, and Rudy and Dash on social medial, then the first person to ‘like’ this was Dr Andy Whittamore. Andy is a GP and clinical lead at Asthma UK, and I took this opportunity to thank him for the work and fantastic resources that they have on the Asthma UK website. Their website is well laid out, and the search function always finds me what I need.
After I have conducted an asthma annual review via telephone, and for just about every contact I have with a person with asthma, I send a text message with a link to one of the resources on Asthma UK’s website. If it’s not a video on inhaler technique, information about preventer inhalers, or MART therapy, then its peak flow information or advice about Covid-19 and the pandemic.
Andy told me that they were planning more things on digital healthcare, and reminded me about their You Tube channel, which has some very simple and meaningful advice to help people with asthma deal with the fear around Covid-19:
He also reminded me about the Asthma At Risk Checker, which takes about 2 minutes to complete, and helps people to self-manage their asthma.
Asthma UK also have one of the best Asthma Action Plans out there. There’s a version for adults and a version for children. When I worked for Sheffield CCG, one of the commissioners asked me what the one intervention would be that could reduce asthma admissions. I told him: an individualised asthma action plan. When he challenged me on this, I pointed him in the direction of the Cochrane Review (the highest quality of clinical evidence), which showed that individualised asthma action plans, along with education and regular professional review, can have a benefit on clinical outcomes in asthma 1. Although there have been other reviews that question the clinical evidence around asthma action plans, they are recommended in national and international guidelines, and an important recommendation from the National Review of Asthma Deaths 2. Ever since then, I’ve been a firm advocate of asthma action plans, and use the Asthma UK versions every time.
I’m fortunate that our System One template (produced by Ardens 3) includes the Asthma UK plan. When you open it up, it populates automatically with your patient’s name and current medications. You can edit and individualise this, and include your patients best peak flow, and whatever action points you choose to use. I use 75% and 50% (purely because I find this quick and easy to calculate) but other people use 80% and 60%, and some even use 80%, 60% and 40%. Personally, I think knowing your best peak flow, when to increase your preventer, and when to seek urgent medical advice is simple enough. Asthma UKs Green, Amber, Red zones in their asthma action plan suit this ideally.
All this reminded me of the asthma annual reviews that we are doing via phone. Naturally we’re all gutted that QOF has been given a holiday, but annual reviews by a health professional who has knowledge, education and enthusiasm for asthma are still essential.
Many nurses I’ve spoken with over the years have been horrified about having to do a phone review for asthma. You can’t check your patient’s inhaler technique or show them how to use the new inhaler you want to give them. You can’t judge their reactions, do their lung function, listen to their chest, or observe their respiration rate. Perhaps it’s harder to build that relationship, or to have that personal touch. And getting hold of them on the phone can be a nightmare; although with the lockdown it does seem to be a heck of a lot easier.
Like most surgeries, we have been using text messaging to get information to patients, and to encourage them to respond. If they are coming into the surgery for a face to face appointment, we’ve been sending them Covid-19 screening questions, for example. For this we have some new software called accuRx 4 which integrates nicely into System One and Emis.
There is also built-in template (which accuRx call a ‘Florey’) for asthma which asks the RCP Three Questions, along with how often they’re taking their reliever, and also about smoking. When the patient receives the text, they can reply to the questions, and there is space for them to include free text at the bottom. This is then picked up by you (or another member of the team) and you can then save it to the patient’s medical records. It even has Read Codes that write directly to the notes (although it’s worth double-checking this bit, as I’ve found it doesn’t always code correctly). A few patients have complained that it’s “too ambiguous” and some just don’t answer at all. But on the whole, it has been useful, easy, and allowed us to continue functioning.
We have been using this to initiate our yearly asthma reviews. When the responses come back, we can decide if they need an urgent follow-up (such as if they are using their reliever more than three times a week) or if we can wait and organise a routine review. If they fail to answer text messages or respond to phone calls, we have been sending out text advice such as inhaler technique videos, and importance of preventer inhalers. I will now start sending out Asthma UKs “At Risk Checker” too. I drafted this out for our team to consider, which you can see here: Asthma Recall via text process. I have to stress we haven’t evaluated this yet, and it is still early days, but it looks like it’s working. I’d be interested to hear what others are doing.
We’re also looking to do more video consultations but have been thwarted at the moment due to lack of web cam availability. So, most of our reviews have been over the phone. I always start by checking it’s the right person I’m speaking with, and if its ok for them to chat for a few minutes about their asthma. I like to use the Asthma Control Test as the core for my discussions, as what you’re really trying to understand is if their asthma is controlled or not. It is also great as it helps you to understand the frequency and severity of their symptoms. The Royal College of Physicians 3 Questions is ok for this too, and if someone has no daytime symptoms, no night symptoms, and no activity limitations, then they are probably well controlled.
Always, always, ALWAYS, ask about reliever inhaler usage. Those of you who have been in any educational sessions with me, know that I really emphasise this as being THE most important question you can ask at EVERY opportunity. Over the years I have tracked blue inhaler usage and its overuse to see that it is associated with poor asthma control, asthma attack, admission, and death 2. A patient can tell you that they are fine, their asthma’s well controlled, it’s not stopping them doing anything, and then go on to tell you that they “only take their blue a couple of times a day”.
Occasionally, I have to go down this route:
“You’re using it more than three times a week?” I ask. “Then you’re at risk of having an asthma attack. 5” Pause.
It can be a very difficult thing to do, to challenge someone’s belief. After all you want to build the relationship you have with them. You need to be honest, and make sure they know the difference between relievers and preventers, and how the latter will “treat the inflammation in your air passages that is giving you the cough / chest tightness / breathlessness / wheeze.” Asthma UK have a very good page on preventer inhalers, which is a great way to back-up everything you’ve told them.
When managing Short Acting B2 Agonist (SABA) usage, our practice always limits the repeat prescribing of salbutamol and terbutaline to one every 90 days (which equates to two does a day 6). And when writing the prescription, I have set up a shortcut, so that when I type “sabaasthma” into the Dose box, it automatically populates with: “Take two doses as needed. If you are needing this more than 3 times a week, your asthma may be poorly controlled. Please contact us immediately” which is so much better than “Two puffs as needed” or (one of my pet hates) “Two puffs four times a day” (hear my screams of rage and frustration). For more practical tips, take a look at the Primary Care Respiratory Society’s Right Care resources, including advice from Leeds/Bradford Respiratory Lead Dr Katherine Hickman. More about reliever reliance in my next blog.
I’m a big fan of peak flow meters at home, both for diagnosing, and helping people to manage their own asthma. When prescribing a peak flow meter, on the prescription instructions, rather than the standard “use as directed” I’ve been typing, “Your best peak flow is 500” or whatever their best has been. If you don’t have a recorded peak flow, then use their predicted. Well, if the heart people can “Know your numbers” why can’t lung people? Peak flows will only work if your patient will do them or understands why they are doing them. So careful explanation is needed to get them onside. I know I’ve cracked it when they say, “Do you think I should so some more peak flows?”
And follow this up with text message advice from Asthma UK or Dr Andy’s excellent video on the subject.
Peak flows aren’t for everyone of course, so I also send a text link to the Asthma Control Test with the advice that if their score drops below 20, their asthma may be poorly controlled, and they should contact the surgery for an urgent review. For more super-useful links, see my blog post from 2 April.
So, will telephone reviews change our care and management going forward? Will everything be done over the phone, zoom, text, and interweb? A study in four primary care surgeries showed that more patients could be assessed with phone reviews, and that they were able to access patients who would not normally attend 7 And a Cochrane review on the subject suggests that there is no difference between face to face consultations and remote consultations in terms of exacerbations or quality of life 8.
Emma Vincent, respiratory nurse at University Hospital Leicester, recently tweeted 9:
“I was thinking today that the language we use with patients is really important. I keep hearing ‘when this is over…’, when I reply I often hear myself say ‘when things change…’” Helping people with their expectations seems a huge part of my role currently.”
Maybe then, we need to adjust our own expectations of the new health service, in order to help adjust the expectations of our patients for when things change.
1.Gibson et al 2002. Self‐management education and regular practitioner review for adults with asthma. Cochrane Systematic Review. doi.org/10.1002/14651858.CD001117
2. Royal College of Physicians. 2014. Why asthma still kills. The National Review of Asthma Deaths (NRAD) Confidential Enquiry report (May 2014). www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
5. National Institute for Health and Care Excellence. 2017. Asthma: diagnosis, monitoring and chronic asthma management. nice.org.uk/guidance/ng80
6. Primary Care Respiratory Society: Asthma Slide Rule
7. Pinnock et al. 2003. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 2003;326:477 doi: doi.org/10.1136/bmj.326.7387.477
8. Kew and Cates. 2016 Remote versus face‐to‐face check‐ups for asthma Cochrane Systematic Review doi.org/10.1002/14651858.CD011715.pub2
9. @EmmaVincent_UHL (April 30, 2020) I was thinking today that the language we use with patients is really important. I keep hearing ‘when this is over…’, when I reply I often hear myself say ‘when things change…’ Helping people with their expectations seems a huge part of my role currently. twitter.com/EmmaVincent_UHL/status/1255894963277254656