1804 Survey of discharge practice and review of safety-netting instructions for children attending Emergency Departments in the UK & Ireland with acute wheeze or asthma: a PERUKI study
Authors: Hannah Romanie , Chavasses Richard , Paton James , Walton Emily , Roland Damian , Foster Steven , Lyttle Mark 
Published: December 2022

Aims, Objectives and Background

Acute wheeze is one of the commonest reasons for childhood Emergency Department (ED) attendances. Ongoing recovery following discharge should be supported with robust safety-netting advice including advice for ongoing bronchodilator use. Evidence for recovery bronchodilator dosing is lacking, likely leading to variation in advice across the UK and Ireland.

This study aimed to describe discharge practices, examining consistency and quality of safety-netting advice (including bronchodilator plans) when discharging children with wheeze or asthma, and identify opportunities for improvements

Method and Design

This two-phase study was conducted across PERUKI registered sites between June 2020 – September 2021. Phase 1 consisted of single site survey responses regarding departmental discharge practices for acute wheezy presentations. During phase 2, discharge instructions provided for caregivers underwent formal review. Data abstraction tools were developed based upon existing literature regarding written wheeze safety-netting information, BTS/SIGN 2019 asthma guidelines, NICE safety-netting recommendations and the BTS Asthma Discharge Bundle.

Abstract 1804 Table 1

Analysis of written safety-netting information (n=61)

Type of leaflet1. Discharge – Normal (expected) recovery path50 (81.9)2. Combined discharge and AAP33 (54.1) - Combined discharge (normal & abnormal) and AAP17 (27.9) - Combined discharge (normal recovery) and AAP16 (26.2)3. Discharge – with a Normal (expected) path AND abnormal (unexpected/deterioration) recovery path31 (50.8)4. PAAP/ plan for future episodes only11 (18.0)General Information provided to caregivers*Inhaler and Spacer technique33 (54.1)Overview of information about wheeze23 (37.7)How inhalers work19 (31.1)Expected time course for recovery18 (29.5)Advice on what to do overnight:16 (26.2) - Do not wake to give inhalers overnight9 (56.3) - Continue to administer overnight including waking if sleeping6 (37.5) - Administer only if felt required1 (1.6)Signs of improvement7 (11.5)Inhaler side effects3 (4.9)Red Flags *Unable to speak52 (85.2)Respiratory distress51 (83.6)Inhalers not lasting 4 hours49 (80.3)Audible wheeze40 (65.6)Coughing37 (60.7)Fast breathing or short of breath36 (59.0)Poor feeding or drinking32 (52.5)Looks pale31 (50.8)Not improving after specified period26 (42.6)Drowsiness25 (40.9)Caregiver is worried8 (13.1)Escalation- how to seek help*Contact GP47 (77.1)Call 99945 (73.7)Call / reattend hospital25 (40.9)Call 11119 (31.1)No advice given7 (11.5)Where is red flag and escalation advice describedWithin PAAP/future episodes information only31 (52.5)Within discharge recovery information28 (47.5)None described2 (3.3)GP Follow-up recommendedGP Follow-up (any)38 (62.3)Within 48hr28 (45.9)Within 1 week4 (6.6)Within 72 hr3 (4.9)Other timeframe2 (3.3)Within 2 weeks1 (1.6)Other support*Smoking cessation support offered15 (24.6)Specialist Nurse8 (13.1)Asthma Clinic4 (6.6)Open access (OA)3 (4.9)Community Nursing Team (CNT)3 (4.9)General Paediatric Clinic1 (1.6)

* Percentages may be greater than 100% as more than one could be selected

Results and Conclusion

This two-phase study was conducted across PERUKI registered sites between June 2020 – September 2021. Phase 1 consisted of single site survey responses regarding departmental discharge practices for acute wheezy presentations. During phase 2, discharge instructions provided for caregivers underwent formal review. Data abstraction tools were developed based upon existing literature regarding written wheeze safety-netting information, BTS/SIGN 2019 asthma guidelines, NICE safety-netting recommendations and the BTS Asthma Discharge Bundle.

National comparison of discharge practices and written safety-netting information for wheezy children attending EDs showed wide variation. This highlights the need for evidence-based guidance to improve and standardise care, providing consistent discharge and safety-netting advice for carers.