From the Trainer
Assistant Director (GP), South East Scotland, UK
E-mail: judith.richardson{at}nes.scot.nhs.uk
At our fortnightly clinical meeting between the GPs and practice nurses, we were discussing the recent crop of interesting patients and difficult management problems when the lead asthma practice nurse raised a significant event about acute asthma care in the practice. The practice nurse raised the issue of having been faced with a patient having an acute asthma attack, the duty doctor not being able to attend immediately and the lack of a Patient Group Direction (PGD) to allow the practice nurses to administer salbutamol either via the nebulizer or spacer. Following her presentation, a number of the doctors and nurses also raised similar cases; in fact, the GP Specialist Registrar (GPStR) and I had been discussing the lack of a spacer in the practice on call bags only the previous week. We identified the core issues arising from the cases discussed and agreed an action plan that involved the lead asthma nurse and GP reviewing the acute asthma protocol to include PGDs available for asthma care.
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As our GP who leads on asthma care is on extended leave, it fell to me (I am not sure how that happened!) to work with the lead asthma nurse. I suddenly became aware of a large knowledge gap in current asthma care and just how much of the chronic disease management is done by the practice nurses. I also realized that although I had been discussing PGDs for years in the practice, I had little understanding of where they originate from and the legal basis of them. With my learning needs well and truly identified, I now needed to think about how I would fill the gaps. I thought about going on an asthma course, reviewing the literature and using the vast resources on the World Wide Web. I could have also read the article on acute asthma in this month's InnovAiT (had it been published).
If I was a GPStR, I would have been able to fill in my ePortfolio with an entry relating to the significant event analysis that had taken place, what I had learnt from it and what I still needed to learn and how I was going to set about doing this. This entry once validated by my trainer would have dropped into my Personal Development Plan (PDP). However, as a trainer, I just added it to my BMJ learning PDP for discussion at my annual appraisal.
So what resources did I find and how useful were they to me?
With regard to the management of acute asthma in primary care, I found the following resources:
- The British Thoracic Society and Scottish Intercollegiate Guidelines Network (have produced a joint guideline—British Guideline on the Management of Asthma (www.sign.ac.uk/pdf/sign63.pdf). This is an excellent resource and I would consider it to be core knowledge for GPs.
- We have an excellent menu of local GP courses provided through our NHS Education for Scotland; however, the next respiratory disease update was not until September which was too far away to address my immediate learning needs and probably not focused enough on the needs I had identified. So perhaps something for the future but not high on the list of priorities.
- The RCGP curriculum map (www.rcgp-curriculum.org.uk/extras/curriculum/index.aspx) suggested the Chest Medicine section of GP notebook (www.gpnotebook.co.uk/) which was an excellent resource for the management of acute asthma in adults and children.
- BMJ learning (www.learning.bmj.com/learning/goto-channel.html) currently has seven modules on asthma. The modules on ‘Asthma in adults: management’ and ‘Childhood asthma: diagnosis and treatment’ were very informative and a useful way of testing what I had learnt from other sources.
With regard to PGD:
- In England, the NHS Patient Group Directions website (www.portal.nelm.nhs.uk/PGD/default.aspx) and in Scotland the NES Patient Group Directions website (www.nes.scot.nhs.uk/pgds) provide a useful overview to PGDs; however, neither site have example PGDs on Asthma.
- A Google search on ‘PGD asthma’ found a PGD for ‘Nebulized Salbutamol in Acute Asthma Care’ on the Brighton and Hove City Teaching Primary Care Trust website (www.brightonandhovepct.nhs.uk/healthprofessionals/clinical-areas/prescribing/pgds/). This is a good example of what a real PGD looks like and is very similar to our local asthma PGD.
So, having addressed my learning needs, I met with the lead asthma nurse in the practice who had been busy gathering together the local PGDs for asthma care, we discussed the outline of the practice protocol and following the meeting the nurse drafted a practice protocol for the management of acute asthma in the practice. We used e-mail to agree some minor modifications to the protocol and then presented it at the next clinical meeting. The protocol was approved and has now been implemented.
I felt pleased that the raising of a significant event by the nurse had led to the identification of not only a practice need but also personal learning needs. That both the practice and personal needs had been successfully addressed and change negotiated and implemented in the practice. Hopefully, the next patient with acute asthma will receive swift and evidence-based care.
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