24. BTS/SIGN asthma guideline
In this series featuring information for patients and professionals taken from evidence-based guidelines, we reproduce the ‘patient education and self-management’ section from the 2005 update of the BTS/SIGN British Guideline on the Management of Asthma
Personalised asthma action plans
Written personalised action plans as part of self-management education have been shown to improve health outcomes for people with asthma.
The evidence is particularly good for those in secondary care with moderate to severe disease, and those who have had recent exacerbations where successful interventions have reduced hospitalisations and A&E attendances in people with severe asthma.
A consistent finding in many studies has been improvement in patient outcomes such as self-efficacy, knowledge and confidence.
A Patients with asthma should be offered self-management education that should focus on individual needs, and be reinforced by a written action plan.
A Prior to discharge, in-patients should receive individualised asthma action plans, given by clinicians with appropriate training in asthma management.
(A = grade A recommendation)
The term ‘action plan’ is proposed as a replacement to the existing ‘self management plan’. It reflects patient terminology preferences (unpublished data from the National Asthma Campaign), may be perceived as less daunting and is appropriate when working with parents and carers as well as adult patients.
There is wide variation in the construction of education/self management programmes and it has not been feasible to isolate each component of such a programme and subject it to rigorous analysis. While the self-management education package is effective, no individual component is consistently shown to be effective in isolation.
Successful programmes vary considerably, but encompass:
- structured education, reinforced with written personal action plans, though the duration, intensity and format for delivery may vary
- specific advice about recognizing loss of asthma control, though this may be assessed by symptoms or peak flows or both
- action to take if asthma deteriorates, including seeking emergency help, commencing oral steroids (which may include provision of an emergency course of steroid tablets), and recommencing or temporarily increasing inhaled steroids, as appropriate to clinical severity. Many plans have used a ‘zoned’ approach.
A range of different patient populations are included in the trials. It cannot be assumed that a successful intervention in one setting will be feasible or appropriate in another. The greatest benefits are shown in those with the most severe disease. The limited number of primary care studies show less consistent results, perhaps because clinical benefit is harder to demonstrate in mild patients.
Innovative approaches to selfmanagement education in teenagers (web-based, peer delivered within schools) appear to have more success than more traditional programmes.A different approach may be needed for pre-school children, many of whom have viral induced wheeze.There are no studies which specifically address the provision of self-management education for the elderly.
Successful interventions have been delivered by trained asthma health care professionals, usually doctors and nurses in the UK, and have been supported by educational discussion. Many published studies report long, intensive programmes. However, there is evidence that short programmes are as effective, and that usual care can be raised to a standard that incorporates many of the core elements of the extensive successful programmes (see Checklist 1).
Self-management programmes will only achieve better health outcomes if the prescribed asthma treatment is appropriate and within guideline recommendations. There is some evidence that patients who are provided with an asthma action plan receive more effective treatment.
B Introduce asthma action plans as part of a structured educational discussion.
(B = grade B recommendation)
Patient education and self management tools
A number of educational tools are available to support health professionals, many of which are free, well researched and non-promotional.
Amongst these are the Be in Control materials produced by the National Asthma Campaign, accessible from the website (www.asthma.org.uk/about) or by contacting the organisation.
Annex 8 reproduces the National Asthma Campaign asthma action plan.
Additional support and information for patients and carers is also available from the National Asthma Campaign website (www.asthma.org.uk) and their nurse run helpline: 0845 701 0203.
|Checklist 1: Setting up a structured asthma programme|
|Checklist 2: Suggested content for an educational programme/discussion|
This checklist is intended as an example, which health professionals should adapt to meet the needs of individual patients and/or carers.The purpose of education is to empower patients and/or carers to undertake self-management more appropriately and effectively. Information given should be tailored to the individual patient's social, emotional and disease status, and age. Different approaches are needed for different ages
Patient education and self management in practice
The programmes evaluated used a wide range of approaches, making it difficult to give definitive advice.
Checklists 1 and 2 (above) are drawn from components of successful programmes, and may be useful when developing educational and organisational aspects of asthma care.
Every asthma consultation is an opportunity to review, reinforce and extend both knowledge and skills. This is true whether the patient is seen in primary care, the accident and emergency department, the ward, or the outpatient clinic. It is important to recognise that education is a process and not a single event.
√ A hospital admission represents a window of opportunity to review self-management skills. No patient should leave hospital without a written asthma action plan.
√ An acute consultation offers the opportunity to determine what action the patient has already taken to deal with the exacerbation. Their self-management strategy may be reinforced or refined and the need for consolidation at a routine follow up considered.
√ A consultation for an upper respiratory tract infection or other known trigger is an opportunity to rehearse with the patient their selfmanagement in the event of their asthma deteriorating.
√ Brief simple education linked to patient goals is most likely to be acceptable to patients.
(√ = good practice point)