A randomized controlled evaluation of specialist nurse education followingaccident and emergency department attendance for acute asthma

We investigated whether hospital-based specialist asthma nurses improved re cognition and self-treatment of asthma episodes by patients followed up aft er attending accident and emergency departments (A&E) for asthma exacerbati ons. We carried out a randomized prospective controlled trial of adult asthma se lf-management, following a hospital outpatient nurse consultation in two ou ter-London District General Hospitals (secondary care centres). The study included 211 adults, over 18 years old (mean age 40 years) who at tended for asthma in two accident and emergency departments over 13 months. One hundred and eight evaluable patients were randomized into the control group who continued with their usual medical treatment and were not offered any intervention during the study period. One hundred and three evaluable patients were randomized into the intervent ion group. They were offered three 6-weekly outpatient appointments with on e of two specialist asthma nurses for a structured asthma consultation, aft er attendance at the accident and emergency department. Following assessmen t of their asthma treatment and control, the nurses advised patients, throu gh the use of self-management-plans, how to recognize and manage uncontroll ed asthma and when to seek medical assistance. Medication and inhaler devic e type were altered if necessary. The primary outcome was patient reported self-management of asthma exacerba tions for 6 months. Secondary outcomes were assessed at baseline, 3 months and 6 months. These included home peak flow and symptom diaries, structured telephone questionnaires and audit of general practitioner records to dete rmine utilization of services (6 months before and after A&E). Data were an alysed on an intention to treat basis by multiple and logistic regression. The intervention group increased their use of inhaled topical steroids in 3 1/61 (51%) vs. 15/70 (21%) attacks in controls (OR 3.91 CI 1.8-8.4, P < 0.0 01) and their use of rescue medication in 54/61 (89%) severe attacks vs. 53 /70 (76%) controls (OR 2.88 CI 1.1-7.9, P < 0.05). Intervention patients ha d significantly higher (mean 20.1 l min(-1); CI 0.4-39.7; P < 0.05) and les s variable PEF and significantly lower and less variable symptom scores 6 m onths after entry. Thirty-four percent of intervention patients vs. 42% con trols had severe attacks (61 and 70 respectively, OR 0.96 CI 0.7-1.4) durin g the 6 months. Intervention patients had fewer days off work than controls in the first 3 months (NS) but similar days off during the 6-month period. Intervention patients had fewer episodes away from work in the first (0.34 vs. 0.54, P = 0.08) and the second 3 months (0.25 vs. 0.30, NS) than the c ontrols. Over 80% of the patients records were audited by their general pra ctitioners; the active group had less routine consultations with the doctor (P = 0.03) and practice nurse (P = 0.03), less consultations for uncontrol led episodes (P = 0.06) and less hospital visits (NS) than the controls. Hospital-based specialist nurses reduced asthma morbidity by improving pati ent self-management behaviour in acute attacks leading to reduced symptoms, improved lung function, less time off work and fewer consultations with he alth professionals.