Transformation Partners in Health and Care > Our partnerships work > Children and young people > Asthma > Setting up an asthma service high risk register for children and young people with asthma

Setting up an asthma service high risk register for children and young people with asthma

25 September 2021

By Jo Massey, Children’s Asthma Nurse Specialist in Croydon



Croydon’s Children’s Asthma Service makes up part of the Children’s Hospital at Home Team at Croydon Health Services NHS Trust.  The team comprises two Children’s Asthma Nurse Specialists, who have a shared passion for improving asthma care for children. Our role is to deliver education to children and young people with asthma in our borough, to help them self-manage their condition.

Like any long-term health condition, some patients’ health is more severely affected than others. Two years ago, therefore, we decided to set up a high risk asthma patient register. Children who were considered high risk, due to the nature of their condition, associated co-morbidities, or frequent asthma-related hospitalisation, were added to our register.

Why did we need a high risk register?

Historically, our team has provided a one-off intervention only, discharging most patients back into the care of their GP. However, this doesn’t work for everyone and some children and their families needed more intensive or regular intervention. We wanted to provide consistent, tailored support, as well as meeting service provision standards and recommendations made in the London Asthma Standards (2020). These standards were most recently revised in December 2021. If you would like more background information about the standards, including the group that compiled and revised them, please see this version from 2020.

First steps

The criteria for inclusion on the high risk register was guided by the Standards mentioned above, but we also included children with persistent uncontrolled asthma, unstable asthma with a confirmed food allergy, and children with other co-morbidities or underlying health conditions.

Eligibility for inclusion would be determined during our initial assessment, with a simple tick box used to record this on our documentation. This acted as a prompt to add the child’s details to the register after the intervention.

The register includes patients’ Asthma Control Test scores, adherence to treatment, named consultant (if appropriate) and clinic appointment dates.

Around this time, we also met with the Trust Informatics Team, who arranged for us to receive daily email notifications for any child aged 2-18 years who attended hospital with asthma. While this did not specifically identify high risk patients, it did mean that if a high risk asthma patient attended hospital, our team would be notified. This proved invaluable in facilitating a timely follow-up for these children.

The interventions

For the majority of patients, 3-6 monthly telephone consultations are used to gain information on patients’ symptom control, adherence to treatment and current inhaler and spacer usage.

Prior to the telephone consultation, we are able to assess patients using their existing records to identify their medical history. This includes reviewing GP prescription records, the number of rescue and preventer inhalers ordered, the number of courses of oral steroids, and any further hospital admissions/ED presentations or GP visits for asthma treatment over the last 12 months.

Working collaboratively across the borough’s health and care system, we ask Croydon GPs to add a high risk patient warning onto the child’s records on their systems, and we added warnings on our systems too. All patient documentation is saved onto their records, so that any clinician looking after a child, whether they’re based in the community or in the hospital, is aware they are a high risk patient.

A child’s consultant also receives a copy of their telephone review and updated asthma action plan and, where possible, we try to attend joint consultant appointments.  This works particularly well for shared care patients, who may also be under a tertiary care centre for asthma treatment.

High risk patients are discussed within the Asthma Nursing Team and during monthly clinical supervision with a hospital consultant. We also discuss cases regularly with GPs and practice nurses working in primary care, to promote a collaborative approach to asthma care.

Children and young people on the high risk register receive seasonal, targeted text messages and this April we shared our very first patient newsletter!

What were the challenges?

Like any new initiative, there have been some challenges. Some children and their families need frequent support and surveillance, and this has inevitably resulted in a huge increase in our workload.

As a small team, this means prioritising our time effectively, which can be difficult during the winter months when demand can increase substantially. However, it is something that we both really felt was a worthwhile and valuable project and we have dedicated time to making this a success.

The benefits far outweigh the challenges!

Improved asthma control. When auditing our patients, we found that by providing more intensive input, nearly all of the children on the high risk register had improved Asthma Control Test scores and therefore a better asthma-related quality of life. Many were more adherent to their preventer treatment than before, although it was unclear whether this was due to our input or because they were aware their prescription records were being monitored! Children had inhaler and spacer devices that they liked, and that were in line with paediatric licensing and national guidelines.

Improved quality of care. More regular surveillance and better support led to a higher quality of care and reduced the risk of further asthma exacerbations and hospitalisations.

Identification of areas for development. This project enabled us to identify the current gaps in service provision and areas for development, such as referrals to secondary care, communication between services and development of our existing service.

Better working relationships. A ‘teamwork’ approach with other healthcare professionals definitely leads to a seamless approach between primary, secondary and tertiary care. This has helped us meet the needs of our patients, provide the best care possible and ultimately improve outcomes for children and young people with asthma.


See more from #AskAboutAsthma 2021