Step 3a. Develop aims – consider particular service user groups

Your aim to improve respiratory care in line with guidance, should be specific (e.g. all people with respiratory conditions or limited to particular groups); timebound (e.g. in next quarter, at next medication review); aligned (e.g. to guidance and local formulary choices), numeric (e.g. target percentage change).

Suggested actions - developing aims, project planning

People with undiagnosed respiratory conditions – using SABA alone

• Ensure correct diagnosis, referral for spirometry IPCRG guide to spirometry, ARTP statement on spirometry or as per your local Board/MCN guidelines
• Peak flow diary Peak flow recording
• FeNO, PCRS consensus on FeNO testing, X-ray, CT scan (where appropriate) 
• Correct management on diagnosis 

Uncontrolled asthma – detected by SABA over-reliance - Asthma slide rule, Are you over-reliant on your SABA inhaler? Rate your reliance

Poor adherence to ICS – Check ordering history

• Check inhaler technique at every opportunity RightBreathe, UK Inhaler Group standards
• and issue self-management plans Asthma + Lung UK asthma action plan, Completing an asthma action plan | Asthma + Lung UK, Chest Heart & Stroke Scotland Traffic light plan for COPD, Asthma + Lung UK COPD self-management plan 
• Consider use of MART or AIR.

COPD : people who frequently experience exacerbations requiring steroids and/or antibiotics

• Ensure optimal symptom control (Use COPD Assessment test)and management utilising pulmonary rehabilitation, activity, COPD self-management plans and enquiry regarding smoking  - offering smoking cessation advice if needed.
• Education regarding when to use rescue medication PCRS - The appropriate use of rescue packs, objective measurements (e.g. pulse oximeter, sputum and symptom scoring) and optimising medication. Antibiotic stewardship, When to issue steroid cards HIS Steroid emergency card guidance.
• When to offer bone protection. Referral of frequent exacerbators for further investigation and potential macrolide treatment.

High dose ICS use

Check symptom control (ACT Asthma Control Test or equivalent), check adverse effects such as oral thrush. Reduce to lowest maintenance dose, check adherence, inhaler technique, bone protection and steroid card issue.

Severe asthma

Optimise therapy, check adherence and inhaler technique. Objective measurements (sputum sample etc.) and referral. 

Use Scottish Therapeutic Utility (STU) to identify (groups of) individuals in GP practices  

• Information and download instructions for practices
• STU installation

Identifying people at risk

• Diagnosis - COPD | Diagnosis | Chronic obstructive pulmonary disease | CKS | NICE
• What actions are taken to follow up people with asthma within 48 hours of an exacerbation (if not hospitalised, or after discharge if hospitalised?)
• Spirometry for repeated breathlessness and prolonged episodes of cough, smoking history, use of peak flow diaries and ICS reversibility, sputum sampling, differential diagnosis excluding heart failure and GORD, screening for AAT deficiency.
• Red flag investigations e.g. Blood tests, X-ray, CT. 

Differential diagnosis

• Consider other causes of breathlessness such as heart failure
• Address breathing dysfunction – referral to chest physiotherapist where available Dysfunctional breathing | RESPe (respelearning.scot)
• Breathlessness resources to assist individuals
• Cough pathway

Polypharmacy

• National therapeutic indicators
• Polypharmacy-Guidance-2018.pdf (scot.nhs.uk)

Focus on disadvantaged groups

This may include minority ethnic groups, those with English as an additional language, low literacy, mental health conditions., people living in adversity, poor housing etc.

How are they supported – leaflets in additional languages, community outreach work?

• Depression and anxiety patient health questionnaire (PHQ-9), PHQ4,  Generalised anxiety disorder assessment (GAD-7)
• Scottish Government publication: Improving the physical health and well being of those experiencing mental illness
• Guides to help patients manage their asthma in different languages Poster with QR codes and links in different languages, Easy read asthma leaflet
• Videos in different languages to guide inhaler choice Inhaler choices | Asthma + Lung UK (asthmaandlung.org.uk)

Patient identification and prioritisation

• Use the National Therapeutic Indicators (NTIs) to identify variation between boards, clusters or practices.
• Individuals within each group can be identified using the Scottish Therapeutics Utility (STU) in general practice