Search

Objective: To ascertain the standard of care for hospital management of acute severe asthma in adults., Design: Questionnaire based retrospective multicentre survey of case records., Setting: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland., Patients: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management., Main Measures: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians., Results: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan., Conclusions: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians.

Objective: To assess whether the management of asthma has improved from three consecutive surveys., Design: Retrospective case note survey of acute asthma admissions in 1983 and 1989; case notes selected from 1985-6 survey of prospectively identified patients to include only patients with a final discharge code of asthma., Setting: A large city teaching hospital. Patients--101 patients with acute asthma as the primary diagnosis in 1983; 85 in 1985-6; and 133 in 1989, 14 of whom were subsequently transferred elsewhere., Main Measures: Conformity with a checklist of important aspects of the process of asthma management including initial assessment, treatment, supervision, and discharge and review arrangements., Results: All patient groups were similar in age, smoking habit, and stay in hospital and, as an objective guide to severity of asthma, had similar initial pulse rates. Major improvements occurred in management: by 1989, 119(90%) patients were treated with oral corticosteroids (69(68%), 67(79%) in 1983, 1985-6 respectively) and 109(82%) with oxygen (62(61%), 51(60%)) (both p < 0.001). 114(86%) had regular recording of peak flow measurements (53(52%), 54(64%); p < 0.001), and 103/119(86%) were discharged taking oral corticosteroids (66(65%), 63(74%); p < 0.01). Significantly fewer patients, however, had their regular inhaled corticosteroid treatment increased on discharge (38/119(32%) v 53(52%), 39(46%); p < 0.01), but more were receiving high dose inhaled treatment on admission., Conclusions: The management of asthma improved significantly, and the normal practice of doctors has changed in an area of practice with longstanding problems.