The asthma clinic is held on a weekly basis, four times per month, two hours per clinic. The first three weeks of the month adult asthmatics are seen, the fourth is a children's clinic. Attendance is initially either via nurse or doctor, although the clinic is well publicised within the surgery.
Initial appointment
A patient attending the clinic for the first time is allocated a 20 minute nurse appointment, followed by a 10 minute doctor allocation. The practice nurse enters information on an asthma record card which is kept in the patient's notes. She records:
The nurse also educates the patient with regard to asthma and inhaler technique. The GP reviews the nurse recorded information and the patient's drug regime, making any appropriate changes. He/she then decides on a review date and the patient is asked to make a further appointment (a reminder is sent our two weeks prior to the review).
Review appointments
Subsequent appointments are given a ten minute nurse allocation, with doctor time available (if necessary) throughout the clinic. At review appointments the nurse records:
Symptoms, inhaler technique and education are again discussed. If the nurse thinks a doctor assessment is appropriate the patient will then be seen by the GP who would review the initial assessment. Nurse and doctor meet at the end of each clinic to discuss patients and ensure continuity of care.
Administration A patient is invited by letter to attend the clinic but if he/she defaults a further (different) letter is sent. If a patients does not respond to this invitation no further appointments for the asthma clinics are made and the patient is seen routinely, by doctor only, in the surgery. A note of all attendances and defaulters is kept in a manual register which is updated after each clinic. Patients admission to hospital for asthma is also recorded.
Protocols of Care
Step 1
Bronchodilators. A B-agonist such as Salbutamol or Terbutaline to be used as required to relieve symptoms by all asthmatics. For those with infrequent wheeze and no nocturnal symptoms this may be the only treatment necessary.
Step 2
Inhaled anti-inflammatory agents to be given regularly to all those who need to use their bronchodilator more than once daily or have night time symptoms. Appropriate options are:
Step 3
If control (symptoms, PEFR, use of bronchodilators) not adequate, either high dose inhaled steroids are given through a large volume spacer device to maximum daily dose of 2mg (800 mcg in children), or low dose inhaled steroids plus regular inhaled long acting beta stimulant.
Step 4
Additional bronchodilators tried sequentially:
Step 5
Maintenance oral corticosteroids are given only if control is shown to be inadequate on maximum doses of inhaled therapy. At this point patients will usually be referred to hospital.
Short course oral steroids
These may be required for initial control and at any time to control exacerbations. Prednisolone 30mgm daily (60mgm if on maintenance oral steriods) until two days after full recovery.
Treatment is reviewed regularly and stepped down again as appropriate. The steps of treatment are used appropriately according to the severity of disease in order to gain control of symptoms.
Asthma Clinic
Asthma clinics continue to be held weekly run by Sister Susan Hetherington (Practice Nurse). A total of 29 new asthmatic patients have attended the clinic this year, patients are usually recalled to the clinic every 6 - 12 months, depending on their level of asthma control. Education on inhaler use and asthma management continues to be the main objective of the clinic.
The Practice has recently acquired a Vitalograph spirometer which will prove to be a useful tool in determining the severity, and subsequent treatment and management of patients suffering from chronic obstructive airways disease. Both practice nurses have been trained to use the spirometer, so that it may be used to measure airway reversibility testing in all patients with airways disease.