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Inhalation JUNE 2016 27 Organization of NHS Services 1. Every NHS hospital and general practice should have a designated, named clinical lead for asthma services, responsible for formal training in the management of acute asthma. 2. Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids, oral or injected, in the previous 12 months or require management using British Thoracic Society (BTS) step- wise treatment 4 or 5 to achieve control. 1 3. Follow-up arrangements must be made after every attendance at an emergency department or out-of-hours service for an asthma attack. Secondary care follow-up should be arranged after every hospital admission for asthma, and for patients who have attended the emergency department two or more times with an asthma attack in the previous 12 months. 4. A standard national asthma template should be developed to facilitate a structured, thorough asthma review. This should improve the documentation of reviews in medical records and form the basis of local audit of asthma care. 5. Electronic surveillance of prescribing in primary care should be introduced as a matter of urgency to alert clinicians to patients being prescribed excessive quantities of short-acting reliever inhalers, or too few preventer inhalers. 6. A national ongoing audit of asthma should be established which would help clinicians, commissioners and patient organiza- tions work together to improve asthma care. Medical and Professional Care 1. All people with asthma should be provided with written guidance in the form of a personal asthma action plan (PAAP) which details their own triggers and current treatment, and specifies how to prevent relapse and when to seek help in an emergency. 2. People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be more closely monitored, ensuring their personal asthma action plans (PAAPs) are reviewed and updated at each review. 3. Factors that trigger or make asthma worse must be elicited routinely and documented in the medical records and personal asthma action plans (PAAPs) of all people with asthma, so that measures can be taken to reduce their impact. 4. An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up. 5. Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the signifi- cance of concurrent psychological and mental health issues. Prescribing and Medicines Use 1. All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required. 2. An assessment of inhaler technique to ensure effectiveness should be routinely undertaken and formally documented at annual review, and also checked by the pharmacist when a new device is dispensed. 3. Non-adherence with preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored. 4. The use of combination inhalers should be encouraged. Where long-acting beta-agonist bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaled corticosteroid in a single combination inhaler. Patient Factors and Perception of Risk 1. Patient self-management should be encouraged to reflect their known triggers, e.g., increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs or by the early use of oral corticosteroids with viral or allergic-induced exacerbations. 2. A history of smoking and/or exposure to second-hand smoke should be documented in the medical records of all people with asthma. Current smokers should be offered referral to a smoking-cessation service. 3. Parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on "how," "why" and "when" they should use their asthma medications, recognizing when asthma is not controlled and knowing when and how to seek emergency advice. 4. Efforts to minimize exposure to allergens and second-hand smoke should be emphasized especially in young people with asthma. Table 1 Key Recommendations of the National Review of Asthma Deaths (NRAD) Reproduced with kind permission of the Royal College of Physicians, London, UK