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Original article

The importance of nurse-led home visits in the

Arch Dis Child: first published as 10.1136/adc.2008.152140 on 21 June 2009. Downloaded from http://adc.bmj.com/ on 21 July 2019 by guest. Protected by copyright.
assessment of children with problematic asthma
M Bracken,1 L Fleming,2 P Hall,1 N Van Stiphout,1 C Bossley,1 E Biggart,1 N M Wilson,1
A Bush1
1
Department of Respiratory ABSTRACT
Paediatrics, Royal Brompton Objective: To evaluate and identify potentially modifiable What is already known on this topic
Hospital, London, UK; 2 National
Heart and Lung Institute,
factors in children with problematic asthma by a nurse-led
Imperial College, London, UK assessment and home visit. c There are many causes for suboptimal asthma
Design: Observational cohort study. control.
Correspondence to: Setting: A tertiary paediatric respiratory centre.
Professor A Bush, Department of c A systematic assessment of children with
Paediatric Respirology, Royal Patients: 71 children, aged 4.5–17.5 years, with problematic asthma is necessary in order to
Brompton Hospital, Sydney problematic asthma currently under follow-up at a tertiary distinguish difficult asthma from severe therapy-
Street, London SW3 6NP, UK; respiratory centre.
a.bush@rbht.nhs.uk resistant asthma.
Interventions: A nurse-led hospital visit followed by a
home visit.
Accepted 2 June 2009
Published Online First Main outcome measures: Identification and attempted
21 June 2009 change of exacerbating factors so that further investiga- What this study adds
tions and consideration of off-label, potentially toxic,
asthma therapies were not necessary.
Results: Potentially modifiable factors were identified in c A nurse-led home visit is an important part of the
56 (79%) children. Many children had multiple causes for evaluation of problematic asthma and can help
poor control. The most important were ongoing allergen to identify potentially modifiable causes.
exposure, 22 children (31%); passive or active smoking, c An effective treatment plan can help to avoid the
18 children (25%); medication issues including adherence, need for further investigations and escalation of
34 children (48%); psychosocial factors, 42 families treatment.
(59%). The home visit contributed valuable information to
this assessment. At the home visit house dust mite
avoidance measures were found to be inadequate in 84%
remain symptomatic despite appropriately admi-
of those sensitised; medications were not easily available
nistered conventional management.5
for inspection or were out of date in 23%; 74% of
Secondary and tertiary care assessments of these
psychology referrals were made after the home visit. In
children and their families usually take place in the
39 children (55%) the factors identified and the
hospital setting. Although useful information can
interventions recommended meant that further escalation
be gained during these meetings, we suspected it
of treatment was avoided.
was often incomplete due to time constraints6 and
Conclusions: Nurse-led assessments including a home
reluctance to disclose sensitive information to a
visit can help identify potentially modifiable factors for
doctor.7 Visiting families at home has been shown
poorly controlled symptoms in children with problematic
to be of benefit in helping patients with asthma
asthma.
develop self-management plans,8 9 to minimise
exposure to home environmental asthma trig-
gers10 11 and to provide psychological support.12
Most children with asthma have their symptoms
However, little is known of how much a home
controlled with low-dose inhaled corticosteroids
visit contributes to the assessment of children with
(ICS). However, approximately 5–10% of asth-
problematic asthma. We have evaluated the out-
matic children have ongoing symptoms and/or
comes of nurse-led assessments as part of the
severe exacerbations despite treatment with con-
difficult asthma protocol, in particular the home
ventional therapy, including high-dose ICS, long-
visit to assess the information gained and effect on
acting b-2 agonists, and leucotriene receptor
outcome.
antagonists.1 2 These patients with problematic,
difficult to manage asthma consume a dispropor-
tionate amount of resources.3 4 There can be many METHODS
reasons for poor symptom control including Eligible subjects were school-aged children with
wrong diagnosis, co-morbidities, poor adherence physician-diagnosed asthma who were currently
to treatment, psychosocial issues, allergen expo- being seen by a respiratory paediatrician at the
sure and active and passive smoking. We have Royal Brompton Hospital (a tertiary centre). They
proposed the subdivision of ‘‘problematic’’ asthma had persistent symptoms (>3 days a week), or
into ‘‘difficult asthma’’, which becomes easier to frequent exacerbations (once a month or more)
treat when basic management, for example despite treatment stage of at least four of the
adherence to therapy, is optimised, and ‘‘severe, British Thoracic Society/Scottish Intercollegiate
therapy-resistant asthma’’, in which the children Guidelines Network guidelines.13

780 Arch Dis Child 2009;94:780–784. doi:10.1136/adc.2008.152140


Original article

Our difficult asthma protocol was divided into three parts: Psychosocial issues
A further opportunity to discuss any issues raised by the

Arch Dis Child: first published as 10.1136/adc.2008.152140 on 21 June 2009. Downloaded from http://adc.bmj.com/ on 21 July 2019 by guest. Protected by copyright.
stage one, the subject of this manuscript, which comprised a
nurse-led hospital-based visit followed by the home visit; stage psychosocial questionnaire at the hospital visit was given and
two, inpatient stay and further investigations including parents often found this a good opportunity to discuss any such
bronchoscopy; stage three, assessment of steroid responsiveness. issues at length. A referral to our clinical psychologist was made
At stage one, factors that were contributing to poor symptom if appropriate and with the family’s agreement.
control were identified and appropriate interventions recom-
mended. Only those children for whom no potentially
Assessment
significant modifiable factors were identified or who still had The findings from stage one were discussed at a multi-
ongoing symptoms despite the stage one interventions con- disciplinary team meeting. Individualised plans of treatment
tinued to stages two and three. and interventions were recommended. In particular, it was
determined whether the child was likely to have true severe,
Nurse-led hospital-based assessment therapy-resistant asthma, with the need to proceed to further
The child and family attended the outpatient department for investigations including bronchoscopy.
the initial assessment. Patient history, including triggers,
environmental exposures, exacerbations in the past year and
RESULTS
family history was recorded. Skin prick tests to common
Between February 2005 and June 2008, 71 subjects were visited
aeroallergens and foods were performed using standardised
at home by one of two paediatric respiratory nurses as part of
extracts and positive and negative controls (ALK-Abelló,
the difficult asthma protocol. The patient demographics and
Hørsholm, Denmark). A positive result was defined as a wheal
baseline measurements obtained during the nurse-led hospital-
size of 3 mm or greater in children aged 6 years or older or
based assessment are shown in table 1.
2 mm or greater in children aged less than 6 years. Exposure to
environmental tobacco smoke was measured using a high-
sensitivity salivary cotinine quantitative enzyme immunoassay Allergen exposure within the home
kit (Salimetrics, Pennsylvania, USA). Inhaler technique was Seventy-nine per cent of children were atopic (at least one
reviewed and corrected if necessary. Permission was obtained to positive skin prick test). The results of skin prick tests, carried
contact the family practitioner and ask for a list of prescriptions out during the hospital-based visit are shown in fig 1. At the
issued. A semistructured questionnaire was used to take a time of the home visit it was found that of the 31 children who
psychosocial history including questions on home life, school, were sensitised to HDM, five (16%) used reasonable HDM
asthma treatment and understanding of treatment. Spirometry control measures (appropriate bedding, hot washing of bed
was performed to measure first second forced expiratory volume linen, damp dusting), 15 (48%) were found to have only some
and forced vital capacity. Bronchodilator reversibility was measures in place and 11 (36%) none. Thirty pet owners were
assessed following 1 mg salbutamol administered by a metered visited, of whom 17 (57%) were sensitised to their own pet. At
dose inhaler and spacer.14 the home visit it was found that 15 (88%) of those sensitised
had not implemented any pet avoidance measures such as the
housing of animals outside. Following the assessment it was felt
Nurse-led home visit
The home was visited by the asthma nurse, with one or both
parents present. The child was not usually present. If the child Table 1 Information obtained at hospital based visit: patient details,
was also under the care of a local team the relevant paediatric medication, spirometry, clinical status and prescription records
community nurse was also invited to participate in the home Total number of subjects (male) 71 (35)
visit. The home visit addressed four main areas: allergen Age, years 11.9 (4.5–17.5)
exposure, smoking, adherence, psychosocial issues. Passive smoking 23 (32%)
Prescribed medication
Dose of FP equivalent (mg/day) 1000 (500–3000)
Allergen exposure Long-acting beta-agonist 70 (99%)
The home was checked for the presence of likely allergens, in Combination inhaler 48 (68%)
particular house dust mite (HDM) and pets and whether any Oral steroids 21 (30%)
steps had been made to reduce exposure (including appropriate Leucotriene receptor antagonist 42 (59%)
bedding, hot washing of bed linen, damp dusting and housing of Stage 1 tests
pets outside). FEV1 prebronchodilator, % predicted 76 (33–125)
Bronchodilator reversibility, % 14 (212–106)
FVC prebronchodilator, % predicted 94 (57–130)
Smoking
Clinical status
Evidence of smoking was noted, and in particular whether this
Admissions in past year 2 (0–21)
took place inside or outside the home. Smoking was judged to
Ever ventilated 12 (17%)
have taken place in the home environment if there was a
Prescriptions issued (%)
characteristic odour in the home, the presence of used ashtrays .80 23 (43%)
or actual smoking was observed. 50–80 17 (27%)
,50 19 (30%)
Adherence Data are presented as number (%) in each category except age, daily dose of
All medications prescribed to the child were checked and the fluticasone propionate (FP), spirometry and number of admissions in the past year that
location of the medicines and ease of access assessed. It was also are expressed as median (range). Prescription data are presented as the proportion of
prescriptions issued during the previous year compared with what should have been
noted if medicines were within their use-by-date and whether issued if adherence to prescribed medication was 100%. FEV1, first second forced
spares were available. expiratory volume; FVC, forced vital capacity.

Arch Dis Child 2009;94:780–784. doi:10.1136/adc.2008.152140 781


Original article

Medication issues including adherence, unsuitable device and


poor technique were felt to contribute to poor symptom control

Arch Dis Child: first published as 10.1136/adc.2008.152140 on 21 June 2009. Downloaded from http://adc.bmj.com/ on 21 July 2019 by guest. Protected by copyright.
in 34 children (48%).

Psychosocial factors
Psychosocial problems were identified in 42 families (59%).
Factors identified are shown in table 2. A total of 39 families
(55%) was referred for further psychological evaluation and
support. Twenty-nine (74%) of these referrals were made only
after further information had been elicited at the time of the
home visit. Twenty-eight children (39%) were assessed to have
psychosocial factors as a major component of their asthma
morbidity, either as a direct cause of their symptoms or as a
consequence of their asthma.

Figure 1 Result of skin prick tests to common aeroallergens and foods.


Outcome
A positive response was defined as a wheal 3 mm or greater in children Fifty-six children (79%) were judged to have potentially
6 years of age or older and 2 mm or greater in children under 6 years. modifiable factors contributing to their poor asthma control
Results are expressed as the percentage positive of those tested. HDM, (fig 2). The interventions recommended as a result of the stage
house dust mite. one visit (combined nurse-led hospital and home visits) are
shown in fig 3. Following the stage one assessment, of the 71
that the presence of allergens in the home was contributing to evaluated only 32 (45%) continued to fulfil the criteria for severe
ongoing symptoms in 22 cases (31%). asthma and went on to have further assessment including
bronchoscopy. For those who had only stage one assessment
further investigations were not necessary either because of
Smoking improved symptom control as a consequence of the recom-
Twenty-three parents reported that they were smokers and two mended interventions or because the underlying cause, such as
subjects admitted to active smoking. Salivary cotinine was very poor adherence, meant that further investigations and
measured in 39 children (26 non-smokers and 13 passive or escalation of treatment would not be the most appropriate
active smokers). The median (range) cotinine levels were strategies.
significantly higher in the passive/active smokers compared
with non-smokers: 0.1 mg/l (0.01–3.5) versus 1.1 mg/l (0.3–16.1)
p,0.001. The two active smokers had salivary cotinine levels of
DISCUSSION
We report that 79% of a group of children, with ongoing poorly
16.1 mg/l and 4.5 mg/l. At the home visit no unreported parental
controlled asthma despite being prescribed high doses of
smoking was found. Among those who smoked, indoor smoking
conventional therapy, had potentially modifiable causes for
was detected in eight. Smoking cessation advice was given to all
their symptoms. These were children with prolonged asthma
parents.
symptoms (mean 9.8 years), most of whom had been under
long-term follow-up in secondary and tertiary care and were
Adherence to treatment being considered for treatments beyond the recommendations
The data from prescription records are shown in table 1. At the of most asthma guidelines. In 55% the contributing factors that
time of the home visit complete medications were not easily were identified and the interventions recommended meant that
available for inspection in 13 homes (18%). In eight homes
medications were found to be past their use-by-date. Fifty-five
families (77%) had a complete set of medications within their
use-by-date available at the time of the home visit.
Following the hospital-based assessment 44 children (62%)
were assessed as having a good inhaler technique, 13 were
average and six had a poor technique. Eleven children were
judged to have been prescribed inappropriate inhaler devices,
most commonly children still using a mask with a spacer, using
a metered dose inhaler without a spacer or unable to use a
breath-actuated device.

Table 2 Psychosocial factors identified.


Psychosocial factor Number (%)

Child anxiety/depression/other psychological issue 20 (28)


Parental anxiety/depression/other psychological issue 20 (28
Perception/dysfunctional breathing 11 (15)
School issues 4 (6)
Social issues 10 (14)
Figure 2 Causal factors. More than one factor could be ascribed per
More than one psychosocial factor could be assigned to each subject. child.

782 Arch Dis Child 2009;94:780–784. doi:10.1136/adc.2008.152140


Original article

those who were passive/active smokers than those who were


from non-smoking families. Although no unreported parental

Arch Dis Child: first published as 10.1136/adc.2008.152140 on 21 June 2009. Downloaded from http://adc.bmj.com/ on 21 July 2019 by guest. Protected by copyright.
smoking was detected at the home visit, indoor smoking was
detectable in a third of households. In the clinic setting most
parents only reported smoking outdoors. Salivary cotinine levels
did not differentiate parents who smoked outdoors and those
who smoked in the home.

Adherence
Treatment issues were the most frequent contributory cause of
poor symptom control. Non-adherence is a well recognised
problem in children with asthma19 and an important cause of
treatment failure.20 The difficult asthma protocol enables two
dimensions of adherence to be assessed—prescriptions dis-
pensed by the general practitioner, and the availability of in-
date medications in the home, although neither is perfect.
Merely collecting a prescription does not mean that the
medication is actually taken. In some homes medications could
not be found and others were located in inaccessible places.
During the home visit, it was sometimes discovered that quite
Figure 3 Interventions recommended following the stage one young children were inappropriately being left to take their
assessment. More than one intervention could be recommended for each medications with no direct supervision. This is in keeping with
child. a recent study that found that by the age of 11 years, 50% of
children with asthma were taking their ICS unsupervised.21
further evaluation, including an inpatient stay and broncho- These findings are pointers to poor adherence, which help to
scopy and escalation of drug therapy, were not needed. build up a picture of the family’s approach and attitude to
The importance of the home environment and the assessment treatment and serve as a basis for useful discussion with the
of adherence based on home visit data has previously been families.
reported;15 however, this is the first study to attempt to
quantify the contribution that the home visit makes to the Psychosocial factors
assessment of the child with problematic asthma. We have A wide range of psychosocial morbidity is seen in patients with
identified key areas in which vital details were obtained at the asthma22 23 and this is reflected in our study. Although tools
home visit that complemented or were in addition to the exist to assess quality of life24 25 we have found a semistructured
hospital-based visit and influenced the evaluation and subse- interview a useful way to establish a dialogue with children and
quent management of these children. their families around sensitive issues. We have found that
parents appear to feel more comfortable at home and are much
Allergen exposure more likely to disclose personal information during the home
Most children who were sensitised to HDM and pets had visit, particularly as the child was usually not present. This is
previously been given allergen avoidance advice. At the home reflected in the high number of psychology referrals made after
visit it was found that in most cases steps taken to minimise the home visit compared with those made after the hospital
allergen exposure were suboptimal. The role of allergen visit (74% vs 26%).
avoidance in the management of asthma is controversial. It has
been suggested that HDM avoidance is of no value whatever.16 17 Disadvantages
However, many of the studies cited did not actually achieve a There are some constraints to carrying out home visits. Our
reduction in HDM levels, yet this is taken as evidence by some catchment area is large and home visits have been carried out up
that a reduction of allergen load is not beneficial. Furthermore, to 60 miles from the hospital. A single visit can take up half a
there are no data in children with really severe asthma. Many working day of an asthma nurse. We have not performed a
children are multiply sensitised and studies that have targeted health economic analysis of these visits, and this is a weakness
multiple allergens have been shown to be of benefit10 and this is of the study. Previously all children referred to us who fulfilled
the approach we have taken. It has been shown that asthma the criteria for problematic asthma were admitted for an
exacerbations are most likely in children who are exposed to high inpatient stay and bronchoscopy. The current cost of this is
levels of allergen, are sensitised to that allergen and have a viral £1053. Since implementing the nurse-led hospital and home-
infection.18 Of these factors, only allergen load is susceptible to based assessments only 45% of those evaluated as part of the
modification. Allergen avoidance measures can be expensive and difficult asthma protocol went on to have an inpatient stay.
the home visit gives an opportunity to identify the key areas for
effective intervention. Home versus hospital assessment
The study would have been strengthened if we had actually It could be argued that this information could have been
been able to measure allergen levels in the home, especially after obtained as effectively as part of the hospital-based assessment.
the institution of new allergen reduction measures. We acknowledge that some of the important data we have
obtained were acquired before the home visit, as part of the
Smoking hospital-based visit. Exposure to environmental tobacco smoke
Twenty-three children in this study had parents who were can be adequately assessed by means of salivary cotinine levels.
smokers. Salivary cotinine levels were significantly higher in An assessment of adherence using prescription records can be

Arch Dis Child 2009;94:780–784. doi:10.1136/adc.2008.152140 783


Original article

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